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Full text of "A reference handbook of the medical sciences, embracing the entire range of scientific and practical medicine and allied science"

A Reference Handbook 

OF 

THE MEDICAL SCIENCES 



p:mbracing the entire range of 



SCIENTIFIC AND PRACTICAL MEDICINE 

AND 

ALLIED SCIENCE 

BY VARIOUS WRITERS 

FIRST AND SECOND EDITIONS EDITED BY 
ALBERT H. BUCK, M. D. 

THIRD EDITION 

COMPLETELY REVISED AND REWRITTEN 
EDITED BY THOMAS LATHROF STEDMAN, A. M., M. D. 



I 



COMPLETE IN EIGHT VOLUMES 



VOLUME EIGHT 

ILLUSTRATED BY NUMEROUS CHROMOLITHOGRAPHS AND THREE HUNDRED 
AND THIRTY-SEVEX HALF TONE AND WOOD ENGRAVINGS 



I 



NEW YORK 
WILLIAM WOOD AND COMPANY 

MDCCCCXVII 



13 






GOPTMOHT, 1917, BT 

WILLIAM WOOD AND COMPANY 



" Aulhorily to use ti 
o( Amtrics. N.nlh D< 
by the Board o( Trust. 
wh,<-h Board of Trust, 
translation* o( the oKc,.. ~c. 
to strength of official prcparut 



comment the Pharmacopeia of the United Stales 
=nn,al Revision, in this volume, h" K--n .r.n.^ 
i of the United States Pharmacop 

n no way responsible for thi 

ighl 



.ted 
il Convention. 
curacy of any 
any BtalementB aa 



VPLE PRESS YORK PA 



LIST OF CONTRIBUTORS TO VOLUME VIII 



EDWARD ADAMS, M.D New York. 

Professor of Surgery, New York School of Chiropody ; 
Attending Surgeon, German Hospital, Out-Patient 
Department; Formerly Lecturer on Surgery, New 
York Post-Graduate Hospital and Medical College; 
and Attending Surgeon, Har Moriah Hospital. 
CHARLES LEWIS ALLEN, ^LD.. .Los Axgbles, C.^l. 
Assistant Professor and Chief of the Neurological 
Chnic, Los Angeles Department, College of Medi- 
cine, University of California; Neurologist to the 
County and Children's Hospitals. 
FRANK BAKER, M.D., Ph.D.. .Washington, D. C. 
Professor of Anatomy, Georgetown University School 
of Medicine, Washington, D. C; Supt., National 
Zoological Park, Smithsonian Institute. 

PAUL E. BECHET, A.B., M.D New York. 

Assistant Physician, New York Skin and Cancer 
Hospital; Attending Dermatologist, Roosevelt 
Hospital, Out-Patient Department; and Assistant 
Dermatologist, Presbyterian Hospital, Out-Patient 
Department. 

A. L. BENEDICT, A.B., M.D Buffalo, N. Y. 

Consultant in Digestive Diseases, City and Columbus 
Hospitals; Attending Physician, Mercy Hospital; 
Editor of The Buffalo Medical Journal. 

ROBERT P. BIGELOW, Ph.D Boston, Mass. 

-Associate Professor of Zoology and Parasitology and 
Librarian to the Massachusetts Institute of 
Technology. 

A. H. BUCK, A.M., M.D New York. 

Editor, Fir.st and Second Editions, Reference Hand- 
book of the Medical Sciences. 

HUGH CABOT, M.D Boston, Mass. 

Chief, Genitourinary Department, Massachusetts 
General Hospital; Assistant Professor of Gen- 
itourinarj- Surgery, Harvard Medical School. 

H. L. CHILES, D.O Orange, N. J. 

Secretary, American Osteopathic Association. 

LEON SOLIS COHEN, M.D Philadelphia, Pa. 

SOLOMON SOLIS COHEN, A.M., M.D., Philadel- 
phia, Pa. 
Attending Physician to the Philadelphia General, 
Jefferson, Rush and Jewish Hospitals; Editor, 
System of Physiologic Therapeutics. 

EDWARD M. COLIE., Jr., M.D New York. 

Attending Physician, New York Nurserj' & Child's 
Hospital. 

WILLIAM T. CORLETT, M.D., L.R.C.P., (Lond.), 
Cle\'eland, O 
Professor of Dernuitology and Syphilology, Western 
Reserve University, School of Medicine. 

DAVID M. COWIE, M.D Ann Arbor, Mich. 

Associate Professor of Pediatrics and Internal Medi- 
cine, University of Michigan Medical Scliool, 
Ann Arbor. 

ALFRED C. CROFTAN, M.D Chicago, III. 

Professor of Medicine, Chicago Post-Graduate 
School; Physician-in-Chief, Saint Mary's Hospital; 
Author, Clinical Urinology, Chnical Therapeutics. 



EDWARD CURTIS, M.D New York. 

Lately Emeritus Professor of Materia Medica and 
Therapeutics, Medical Department, Columbia 
University. 

DAVID BRYSON DELAVAN, A.B., M.D New 

York. 
Surgeon and Professor of Larj'ngology, New York 
Polyclinic Medical School and Hospital; Consult- 
ant to Saint Luke's and General Memorial Hospi- 
tals, and Hospital for Ruptured and Crippled, 
New York Hospital, Vassar Bros. Hospital, Pough- 
keepsie, Stony Wold Sanitarium, and Saint Luke's 
Home. 

J. H. ELLIOTT, M.D Toronto, Can. 

LEONARD W. ELY, M.D... San Francisco, Cal. 
Associate Professor of Orthopedic Surgery, Leland 
Stanford Junior University, Department of Medi- 
cine. 

MARTIN F. ENGMAN, M.D St. Louis, Mo. 

Clinical Professor of Dermatology^ W'ashington Uni- 
versity Medical School, St. Louis. 

A. H. FREIBERG, M.D., LL.D Cincinnati, O. 

Professor of Orthopedic Surgery, Medical Depart- 
ment, University of Cincinnati; Orthopedic Sur- 
geon to Cincinnati and Jewish Hospitals. 

JAMES M. FRENCH, M.D San Diego, Cal. 

Formerly Lecturer on the Theorj- and Practice of 
ISIedicine, Medical College of Oliio; Formerly 
Attending Physician, Saint Marj-'s Hospital, and 
Consulting Physician, Saint Francis' Hospital for 
Incurables, Cincinnati. 

WILLIAM C. GILL, M.D Cle\-el.4nd, O. 

JOHN GREEN, S.B., M.D., LL.D... St. Louis, Mo. 

Late Emeritus Professor of Ophthalmology, Medical 

Department, Washington University. 

ARTHUR R. GUERARD, B.Sc, 1\I.D...New York. 

Examiner in Hygiene, New York University and 

Bellevue Hospital Medical College. 

WINFIELD S. H.ALL, B.S., M.D Chicago, III. 

Professor of Physiolog}', Northwestern University 
Medical School; Lecturer on Physiology, Institute 
and Training School of Y. M. C. A.; Lecturer on 
Dietetics, Mercy Hospital School for Nurses, and 
Wesley Hospital School for Nurses. 

VICTOR C. REISER, M.D New York. 

Director for the East, International Health Commis- 
sion, Rockefeller Foundation, New York. 

FREDERICK L. HOFFMAN, LL.D., Newark, N. J. 
Statistician, Prudential Insurance Company of 
America. 

EDWARD J.\CKS0N, A.M., M.D.. .Denver, Colo. 
Ophtlialmologist to Denver County Hospital; Ameri- 
can Editor, Ophthalmic Review, London; Editor, 
Oplitlialmic Department, American Journal of the 
I\Iedical Sciences. 

GEORGE THOM.VS JACKSON, M.D.. .New York. 
Professor of Dermatologx-, College of Physicians and 
Surgeons, Columbia University ; Consulting Derma- 
tologist, Presbyterian Hospital and New York 
Infirmary for Women and Children. 



LIST OF CONTRIBUTORS TO VOLUME VIII 



ESTHER LESLIE JEKFERIS, M.D New Yoiik. 

Attending Physician, Virginia Day Nursery; For- 
nierlv Assistant Physician Babies' Hospital, <^ut- 
Patient Department, and Chief of ('linic, Depart- 
ment of Pediatrics, O. P. D., New York Iiifiriiiary 
for Women and Cliildrcn; Editorial iVssistant, 
Medical Record, and Lecturer on various medical 
sulijects. 

SMITH ELY JELLIFFE, M.D., Ph.D.. . . New York. 
Adjunct Profes.sor, Diseases of the Mind and Nervous 
Svstem, Post-(irailuate Hospital and Medical 
School; Visiting Neurologist, City Hospital; 
Managing Editor, Journal of Nervous and Mental 
Disea.ses; Editor, Nervous and Mental Monograph 
Series and New York Medical Journal. 

CKOUCH \V. KOSMAK, M.D New Y9BK. 

.\ttending Physician. Lying-in Hospital; Editor, 
,\nicrican Journal of Obstetrics and Diseases of 
Women and Children. 

WILLIAM M. LESZYNSKY, M.D New York. 

Consulting Neurologist, Harlem and I'<'oplc's Hospi- 
tals, New York, and Christ Hospital, ,Icrs('y CJity, 
N. J.; Visiting Neurologist, Lebanon Hospital, 
New York. 

E. H. LEWINSKI-CORWIN, Ph.D New York- 

Executive Secretary, Public Health Committee, 
New York .\cademy of Medicine. 

PERRY M. LEWIS, M.D Bainbridge, Ga. 

Late House Surgeon, New York Throat, Nose and 
Lung Hospital, New York. 

JOHN E. LIND, M.D Washington, D. C. 

Senior Assistant Physician, Saint Elizabeth's Hospital ; 
Associate Psychiatrist, Washington Asylum Hospi- 
tal; Instructor in Psychiatry, Georgetown Medical 
College. 

C.VTIIERINE MACFARLANE. M.D., F.A.C.S. 
Philadelphia, Pa. 

WILLIAM P. MASON, B.S., LL.D Tboy, N. Y. 

Professor of Chemistry, Rensselaer Polytechnic 
Institute. 

CHARLES H. MAY, M.D .■■.■■•• New York. 

Ophthalmic Surgeon, Mount Sinai Hospital; Con- 
sulting Ophthalmic Surgeon, Hellevue, French, 
Italian, and Retl Cross Hospitals. 

MORRIS BOOTH ^^LLER. M.D.. Philadelphia, Pa. 
Professor of Surgery, Philadelphia Polyclinic and 
College for Graduates in Medicine; Surgeon, 
Douglas Memorial Hospital. 

HERBERT 0. MOFFITT, B.S., M.D. San Francisco, 
Cal. 
Professor of Medicine, University of California. 

GEORGE M. NILES, M.D .\tlanta, Ga. 

Professor of Gastroenterology and Clinical Medicine, 
Atlanta Medical College. 

iVLBERT P. OHLMACHER, M.D. . . . Detroit, Mich. 
Late Superintendent, Ohio Hospital for Epileptics. 

EDWARD O. OTIS, A.B., M.D Boston, Mass. 

Professor of Pulmonary Diseases and Climatology, 
Tufts College Medical School; Physician to the 
Department of the Lungs, Boston Dispensary. 

A. S. PEARSE, B.S., Ph.D Madison, Wis. 

Associate Professor of Zoology, University of Wis- 
consin. 

EDWARD W. PETERSON, M.D New York. 

Adjunct Professor of Surgery, New York Post- 
Graduate Medical School. 

W. F. R. PHILLIPS, M.D Charleston, S. C. 

Professor of Anatomy, Medical College, University 
of South Carolina. 



WILLIAM HENRY POTTER, D.D.S.. Boston, Mash. 
Professor of Operative Dentistry, Harvard Univer- 
sity. 

EDWARD PREBLE, M.D New York. 

WILLIAM A. PUSEY, A.M., M.D.. . .Chicago, III. 
I'mfcssiir of Dermatology, (College of Physicians, 
liiivcrsily of Illinois; Dermatologist to Saint 
Luke's and .\\igust:uia Hospitals; Author of "The 
Priiu'iplcs and Practice of Dermatology," etc. 
IIKNRY E. RADASCH, M.Sc, Ml). I'uii.adklimiia. 
Pa. 
A.ssociato Professor of Histology and Kmbryology, 
•JefTersoii Medical (!ollege. 
WILHELMINA A. RAGLAND, M.D... New York. 
h'ormerly Assistant Attending Surgeon, New York 
liilirriiary for Women and Children; Chief of 
('liiile, Department of Gynecology, New York 
Infirmary for Women and Children, O.P.D. ; 
L<'ctiirer on various medical subjects. 

PAUL II. RINGER, M.D Ashbville, N.C. 

W. C. RUCKER, M.S., M.D Washington, D. C. 

Assistant Surgeon General, United States Public 
Health Service. 

HENRY H. RUSBY, M.D Newark, N. J. 

Dean and Professor of Botany, Physiology, and 
Materia Medica, Department of Pharmacy, 
Columbia University. 

BERNARD SACHS, A.B., M.D New York- 

Alienist and Mourologist, Bellevue Hospital; Neurolo- 
gist, Moutil Sinai Ildspital; Consulting Physician, 
.■Vlanhattan State Hospital and Neurological 
Institute. 

JAY F. SCHAMBERG, A.M., M.D.. Philadelphia, 
Pa. 
Professor of Dermatology and Syphilology, Temple 
University, Department of Medicine; Professor of 
Dermatology and Infectious Eruptive Diseases, 
Philadelphia Polyclinic and College for Graduates 
in Medicine. 

H. J. E. SCOTT, M.A., B.C.L., M.D New York. 

Formerly Gynecologist, Demilt Dispensary, and 
Attending Physician, Out-Patient Department, 
Hellevue Hospital; Editor, Witthaus' Essentials of 
('liemLstry and Toxicology, Hughes' Practice of 
Medicine, Gould and Pyle's Cyclopedia of Medi- 
cine and Surger\', and Gould's Practitioner's 
Medical Dictionary. 

FRANCIS J. SHEPHERD, M.D.. . . Montreal, Can. 
Dean and Emeritus Professor of Anatomy, McGill 
University, Medical Faculty. 

BEAUMONT SMALL, M.D Ottawa, Can. 

Attending Physician, Saint Luke's Hospital; Late 
Examiner in Materia Medica, College of Physi- 
cians and Surgeons, Ontario. 

STEPHEN SMITH, A.M., M.D., LL.D.. . New York. 
Commissioner, New York State Board of Charities; 
Considting Surgeon to Bellevue Hospital, Saint 
Vincent's Hospital, and Columbus Hospital. 

,TOHN SPEESE, M.D Philadelphia, Pa. 

Instructor in Surgery, University of Pennsylvania; 
Associate Surgeon, Philadelphia Polyclinic; Sur- 
geon to the Children's Hospital. 

THOM.VS L. STEDMAN, A.M., M.D.. . . New York. 
Editor of the Medical Record; Editor, Twentieth 
Century Practice of Medicine, Author of "A Prac- 
tical Medical Dictionary." 

R.VLPH G. STILLMAN, M.D New York. 

C'hiiic.al Pathologist and Attending Physician, 
Department of Contagious Diseases, New York 
Hospital; Instructor in Clinical Medicine, Cornell 
University Medical College in New York City. 



LIST OF CON'l'RIBUTORS TO VOLUME VIII 



MERVIN T. SUDLER, M.D Lawrence, Kan. 

Professor of Surgery, University of Kansas, School 
of Medicine. 

JOHN M. SWAN, M.D Rochester, N. V. 

Secretary of the American Society of Tropical Medi- 



TERRY M. TOWNSEXD, M.D. 



. New York. 



FRANK P. UNDERBILL, Ph.D. . New Have.v, Conn. 
Assistant Professor of Physiological Chemistry, 
Sheffield Scientific School of Vale University; 
Professor of Pathological Chemistry, Department 
of Medicine, Yale University; Chemist to the New 
Haven Ho.spital. 

FERD. C. V.ALENTINE, M.D New York. 

WESLEY G. VINCENT, M.D., F.A.C.S..New York. 
.Associate in Surgery, New York Post-Graduate 
Medical School and Hospital. 

EMMA E. W.VLKER, A.B., M.D New York. 

Assistant Surgeon, S'ew York Hospital for Ruptured 
and Crippled. 

HENRY B. WARD, A.M., Ph.D.. . Urbana, III. 
Professor of Zoology, University of Illinois; Asso- 
ciate Bi<jlogist, Survey Great Lakes, U. S. Fish 
Commission. 

ALDRED S. WARTHIN, Ph.D., M.D.A.vn .\rbur, 
Mich. 
Professor of Pathology and Director of the Patholog- 
ical Laboratories, University of Michigan. 



RICHARD S. WEISS, M.D St. Lonia, Mo. 

H. GIDEON WELLS, A.M., M.D., Ph.D.. Chicago, 
III. 
Professor of Pathology and Dean in Medical Work, 
University of Chicago; Director of Medical Re- 
search, Otho S. A. Sprague Memorial Institute, 
Chicago. 

ROY.\L WHITMAN, M.D New York. 

Adjunct Professor of Orthopedic Surgery, College 
of Physicians and Surgeons, Columbia t'niversitv; 
Professor of Orthopedic Surgery, New York Poly- 
clinic Medical School; Associate Surgeon, Hospital 
for Ruptured and Crippled. 

ABRAHAM L. WOLBARST, M.D New York. 

Consulting Genitourinary Surgeon, Central Islip 
State Hospital; Visiting Genitourinan,- Surgeon. 
People's Hospital and Beth-Israel Hospital Dis- 
pensary. 

FR.A.NCIS" CARTER WOOD, M.D New York. 

Director of Cancer Research, Columbia University; 
Pathologist and Attending Physician to Saint 
Luke's Hospital, New York. 
HENRY L. WOODWARD. M.D.. Cincinnati, O. 
Attending Physician, Cincinnati Hospital. 

EDWARD L. YOUNG, Jr., M.D Boston, Mass. 

Genitourinary- Surgeon, Massachusetts General Hos- 
pital, Out-Patient Department. 

ABR.\HAM ZINGHER. M.D New York. 

Assistant, Research Laboratorv, Department of 
Health, New York. 



A REFERENCE HANDBOOK 



THE MEDICAL SCIENCES 



strabismus 



Stovaine is amylocaine or diinethyl-amino-benzoyl- 
dimetliyl-ethyl-carbinol hydrochloride with the for- 
mula 

CH;, O.CO.CHe 

CiU/ \CH2.N(CH3)2.HC1 

It crystallizes in small scales which melt at 175° C. ; 
is freely soluble in water, dilute alcohol, and acetic 
ether; only slightly soluble in absolute alcohol. 

Stovaine is a local anesthetic, a substitute for 
cocaine, which it resembles in its physiological action. 
It is claimed that the anesthetic power of stovaine is 
equal to that of cocaine; that it is a vasodilator 
rather than a vasoconstrictor, and that it is from 
one-half to one-third as toxic as cocaine, slightly anti- 
septic, and germicidal. It is not an anodyne when 
administereci subcutaneously, but produces analgesia 
when used in epidural or epidermal injections, espe- 
cially so in the neuralgias, including sciatica. Con- 
centrated solutions sometimes cause tissue injuries, 
and this may be followed by gangrene. In ocular 
surgery when it is used in subconjunctival injections, 
anesthesia is said to be complete in one minute or even 
in some instances less than a minute. When used by 
instillation it causes epithelial desquamation to some 
extent, as does cocaine. 

Stovaine has been used in dentistry preceding ex- 
tractions, but instances have been reported in which 
its use was followed by distressing symptoms, even 
syncope. It has been extensively used abroad in 
lumbar anesthesia. In some instances its use has 
been accompanied or followed by malaise, nausea, 
vomiting, persistent headache, and even collapse, 
although such effects when they do follow rarely 
become dangerous. 

The dose of stovaine is uniform with that of cocaine. 
Solutions should be sterilized by heating to 105° or at 
most 110° C. (never to 120° C , at which temperature 
it is decomposed), and should be injected under or into 
the derma. When borated water is used to sterilize 
the syringe, the latter should be thoroughly rinsed in 
distilled water before drawing in the stovaine solution. 
R. J. E. Scott. 



Strabismus. — This term (sytionym, squint) de- 
notes a condition in which the visual axes are not 
both directed toward the point looked at. It may 
cau.se (U|)li)pia, and the eyes may be seen to be turned 
in different directions. 

Diplopia arising from strabismus is binocular. It 
disappears when either ej-e is covered. It is noticed 
only when light from the object looked at forms a 
sensible image on each retina; and when the visual 
centers are so related to each other as to possess the 
power of binocular fusion. 

Normally, when a certain point is looked at, its 
image in each eye falls on the fovea; and the two 
produce the idea of a single point. When, however, 



the point looked at makes its impression on the fovea 
in one eye, but on some other portion of the retina in 
the other, it generates the idea of two distinct points 
some distance apart, the impression on the fovea 
being referred to a point directly in front of the eyes, 
while the impression on another part of the retina is 
referred in a different direction. Thus, in Fig. 4692, 
representing a case of convergent strabismus, the 




Fig. 4692. — Diagram Representing Convergent .^luint. 

visual' axis of the eye A being directed to the object 
O, the visual axis of the eye B is directed elsewhere, 
to P. 

In the eye A the impression of the point O will be 
made at the fovea; but in the eye B the light from O, 
entering in the direction of the broken line Om, will 
make its impression on the point tn, some distance 
from the fovea. Since the impression is made on A 
at the fovea, it will be correctly referred to the object 
looked at. But in B the impression made at m will be 
referred to a point to one side of the object looked at; 
its position relative to being in the din^ction nF, 




which makes the same angle with the visual axis of A 
as Om makes with the visual axis of B. The image 
of the point received on .1, and referred to its true 
position O, is called the true image. The image 
received at m, and referred to F, in the direction nF, 
is called the fals^ image. 

In Fig. 4093, representing what occurs in divergent 
squint, the eye .1, turned toward the object 0, 



Vol. VIII.— 1 



REFERENCE HANDBOOK OK THE MEDICAL SCIENCES 



receives on its fovea the true iinape. which is referred 
to its proper source; and the eye li receives at m the 
false imane, which, with reference to the true image, 
is referred in the direction nF to F. 

In general, in whichever dinclion the squinting eye 
deriatex, its false image appears to be situated to the 
opposite side of the true one. When the image on the 
right belongs to the right eye, it is called homtmymous 
diplopia. It occurs when the visual axes are crossed 
as in Fig. 4092. When the image on the right belongs 
to the left eye and the image seen to the left belongs 
to the right eye, it is crossed diplopia. This is repre- 
sented in Fig". 4693, and occurs in divergent squint. 
To determine which image belongs to the right eye, 
and whicli to the left, cover one eye and the image 
belonging to it will in.stantly disappear. Or place 
before one eye a piece of colored glass, when the 
image belonging to that eye will appear colored. 

Olijcctire .Sij)ni>toms. — If the squint be well marked, 
inspection will reveal the defect, and show which eye 
deviates. But there is a possibility of error. We 
judge of the direction of the visual axis of by the direc- 
tion of the cornea. Usually the visual axis pierces 
the cornea near its center. But sometimes the visual 
axis deviates, so that, when properly directed, the 
center of the cornea will be turned considerably to one 
sideband the eye will appear to squint. 

('oner Test.- — To determine whether the eye really 
does squint, direct the patient to gaze steadily at a 
certain object, and cover first one eye and then the 
other. If both eyes are properly directed, there will 
be no change of position when either one is covered. 
If one eye has, its visual axis turned elsewhere, 
covering it will not cause any change of position; but 
covering the eye which has been directed toward the 
object will cause the eyes or head to be turned, so that 
the eye which had looked elsewhere may now fix 
on the object. If, however, both eyes have been fixed 
on the object, but only by an undue effort, the covered 
eye will deviate and take such position as can be 
preserved without the undue effort. The test should 
be repeated until the observer is satisfied as to the 
presence or absence of squint. 

Having ascertained that squint is actually present, 
the first point to be settled is whether it is coniitaid 
(concomitant) or paralytic. 

CoMiTANT .sTR.ujisMus is ft Wrong, and usually 
variable, coordination of the movements of the eyes 
with reference to each other, without marked limita- 
tion of these movements in any particular directit)n. 
It commonly apjiears in early childhood; but may exist 
from birth, and more rarely begins during adult life. 

Convergeid squint is the most common form of 
comitant strabismus. In it the visual axes converge 
to a point nearer the eye than the one looked at, as in 
Fig. 4692. In it the diploi)ia is homonymous, and on 
covering the eye which is fixed on the object it turns 
in toward the nose, while the other turns from the 
nose and fixes the object. 

Divergent squitU comes next to the convergent in 
frequency. In this form the visual axes do not con- 
verge enough, either meeting at some point beyond the 
object looked at, or remaining parallel or even diver- 
gent. The diplopia is crossed. When the fixing eye 
is covered it turns out, and the other eye turns toward 
the nose and fixes the object. When the visual axes 
remain always divergent, the squint is said to be 
absolutely divergent. When the visual axes can be 
made to converge, but not enough, as in Fig. 4693, the 
squint is relatively divergent. 

Parallel squint is applied to those cases in which 
the visual axes remain parallel when they should 
converge. 

Vertical squint, in which one visual axis is directed 
more upward or more downward than the other, is 
rare, except as complicating one of the other forms of 
comitant squint. 



Constant squint is always present, the visual axes 
never assuming normal relations. Opposed to it is 
periodic or intermittent squint, which is only present 
part of the time. 

Periodic squint is apt to be most marked when the 
general tone of the nervous system is low, or at times 
of great excitement, or when the eyes are particularly 
taxed. A form of convergent squint, appearing only 
during strong effort of the accommodation, is called 
accommodative squint. Squint dvie to clonic spasm is 
convulsive squint. Closely allied to convulsive is 
hysterical squint. 

Monolateral or monocular squint is the form in 
which it is always the same eye that fixes on the 
object looked at, while the other eye always deviates. 
If the fixing eye be covered it will deviate; while 
the ordinarily deviating eye fixes; but, upon uncover- 
ing, the deviation is soon transferred back to the eye 
which habitually presents it. The large majority 
of cases of comitant strabismus are in this sense 
monolateral. But it must not be supposed that only 
the deviating eye is at fault. The squint is a faulty 
coordination of the motions of the two eyes, and one 
eye constantly deviates because the fixing eye has 
better vision, or sees with less effort. 

Alternating squint is the variety in which the 
deviation is sometimes presented by one eye, and some- 
times by the other; either of them becoming the fixiim 
eye when the other is covered, and continuing to fix 
after the other is uncovered again. It is the opposite 
of monocular squint. 

Absence of Binocxdar Fusion. — Most persons with 
squint do not experience double vision. In some 
cases it is quite obvious why there is no diplopia, as 
where corneal opacity, or a high degree of ametropia, 
prevents the formation of a retinal image in the 
deviating eye. In other cases the reason is less ob- 
vious, yet not hard to understand; as here, although 
the deviating eye presents no abnormal appearance, 
the acuteness of vision is very low. But there is still 
another class of cases in which, although each eye is 
used, it is an independent organ. What is called the 
power of binocular fusion or association is lacking. 

Amblyopia ivith Squint. — In many cases of squint 
there is great defect of vision in one eye without any 
visible cause for it. This may be due to invisible 
defects in the cerebral connections of the eye, in which 
case it may be a cause of squint. It may also be due 
to failure to develop visual power through disuse, 
amblyopia ex anopsia. Or there may even have been 
deterioration of vision, by suppression, to prevent 
annoyance from diplopia. 

Causes of Comitant Squint. — When binocular fusion 
is especially difficult or impossible, or the tendency 
to it unusually feeble, as where the vision of one or 
both eyes is very imperfect. The normal guide to 
coordination of the movements of the two eyes, 
diplopia, is absent; and the nerve centers having for 
their function the coordinaton of binocular movements 
do not attain that normal development which enables 
them to keep the visual axes properly directed to the 
point looked at. Anything which impairs the de- 
velopment of the visual centers or the acuteness of 
vision — as hereditary anomalies, convulsions, pro- 
longed nutritive disorders, injury of the eyeball, 
corneal opacities, or high ametropia — becomes a 
cause of squint. But ametropia has an especial share 
in the causation of squint, as was first pointed out by 
Donders. Normally, the exertion of the power of 
accommodation is accompanied by convergence of the 
visual axes; the full power of the accommodation 
cannot be exerted without strong convergence. Hence 
in hyperopia, where the accommodation must be 
exerted more strongh-, there is a special tendency to 
excessive convergence. 

In myopia the need for complete relaxation of the 
accommodation, even when a near object is looked at, 
may lead to deficient convergence of the visual axes. 



REFERENCE HANDBOOK OP THE MEDICAL SCIENCES 



or divergent squint. In myopia of high degree there 
is also anteroposterior elongation of the globe, 
which is often very marked. This makes the eyeball 
an oval, fitting in an oval socket, in which it cannot 
be turned without changing the shape or direction of 
the socket, by actual displacement of the orbital tis- 
sue. Hence convergence of the myopic eye requires 
excessive effort, while myopia, restricting the range 
of distinct vision, requires that the convergence 
should be especially great. In the highest degrees of 
myopia, the effort at convergence is abandoned, and a 
divergent strabismus permitted. This is at first 
relative and periodic, but because it requires less effort 
gradually becomes more frequent and habitual, so 
that the divergence is very likely to become absolute 
and constant. 

Trenimenl of Comilanl Squint. — The preventive 
treatment should include all measures favoring the 
normal development of the general nervous and 
muscular systems, or calculated to improve the acute- 
ness of vision. Both to influence the acuteness of 
vision, and to give the normal accommodation and 
range of distinct vision, errors of refraction are to be 
corrected. In convergent scjuint with hj'peropia, the 
convex lenses fully correcting the latter should be 
worn constantly. They should be carefully de- 
termined and put on at the earliest date possible. 
Children of two or three years will wear accurate 
correcting lenses with the greatest benefit. To make 
the necessary measurements for lenses, and to enforce 
their use, it is advisable to place the ej-es fully under 
the influence of a cycloplegic as: Atropine sulphate, 
gr. i; distilled water, fl. oij — one drop to be placed in 
each eye three times a day. This should be kept up 
for some weeks until the squint has disappeared, or 
until it is clearly demonstrated that the deviation is 
not being favorably influenced by it. 

The mydriatic acts by paralyzing the accommoda- 
tion, and so preventing any attempt to use it which 
may bring about excess of convergence. Care must 
be taken that the solution used is strong enough, and 
is efficiently applied. If only enough of the drug is 
instilled to somewhat weaken the accommodation, the 
effect will be not to prevent, but to increase the 
accommodative effort, and therefore the accompany- 
ing convergence. Sometimes to eliminate accommo- 
dative effort it is best to give a young child bifocal 
glasses such as would be given for presbyopia. 

In myopia concave lenses, correcting it, may be used 
to prevent divergent squint; or, if the squint is already 
established, to bring about convergence. 

As aiding in the proper development of the muscles 
concerned, what are called orthoptic exercises are rec- 
ommended. They consist usually in looking througli 
some form of apparatus at lines, letters, or figures, a 
part of each being seen by one eye, and the remainder 
being presented to the other eye; by an effort tliese are 
to be fused into one picture. A reading liar or a ruler 
may be placed vertically between the page and the 
eye. The ruler cuts off a part of the page for each 
eye, but by using both eyes all parts may be seen. 
The reading of each line necessitates the alternate use 
of both eyes. The fusion tubes of Priestley Smith may 
be used for children who cannot read. The ambiyo- 
scope of Worth presents diagrams or pictures in such 
positions that it is possible to fuse their images while 
the eyes are strongly converged. By practice witli 
it the "fusion sense" is developed and used to assist in 
overcoming the squint. With older patients the 
ordinary hand stereoscope, or the reflecting stereoscope 
may be employed with special diagrams or pictures 
marked for the purpose. Orthoptic exercises are 
mainly of use to cultivate the faculty of binocular 
fusion where that exists, but is deficient in comparison 
with the obstacles it has to overcome. 

.\s a palliative of comitant squint, prisms may be 
worn in rare instances. They are so used as to cause 
the rays to enter the squinting eye in the direction of 



its visual axis and thus avoid diplopia, while the squint 
remains unchanged. Or they may be used as a sort 
of orthoptic apparatus, to bring the rays so nearly in 
the direction of the visual axis of the deviating eye 
that, by a little additional effort, the visual axis will 
be brought to coincide with their direction and the 
sciuint thus lessened. In either case the strength of 
prismatic effect required is to be determined by trial, 
and secured by placing prisms of equal strength before 
both eyes, with the refracting angle or thin edge of 
the prism in the direction in which the eyes deviate. 

Operative 7neasures are intended so to change the 
connection of the muscles to the eyeball that the visual 
axes may assume approximately their proper positions. 
Division of the tendon of the muscle toward which 
the cornea is turned allows the eyeball to be turned 
toward the proper position by its opponent. This 
is called tenotomy of the rectus, or strabolomy. Ad- 
vnncement of the tendon of the muscle which has exerted 
too little influence on the direction of the eye allows 
it to acquire a new insertion clo.ser to the cornea, and 
to exert a relatively greater influence in determining 
the direction of the visual axis. Tendon transplanta- 
tion, by giving an insertion on a different part of the 
eyeball, enables one muscle to perform the function 
normally belonging to another. Operative procedures 
should only be resorted to after other means have 
been carefully tried and have failed to give relief. 

In determining the operation to be done the 
amount of deviation is to be considered. This may 
be measured in degrees on the arc of a perimeter, by 
placing the deviating eye at the center of the arc, 
making the visual axis of the fixing eye parallel to the 
axis of the instrument, and noting the number of 
degrees from the axis of the perimeter to the visual axis 
of the deviating eye. In place of the perimeter arc, 
the deviation may be measured on a meter stick or 
tape, held one meter from the eyes. It can also be 
measured by placing a scale along the edge of the 
lower lid of the squinting eye, covering the good eye 
so that the other may fix, and then uncovering it and 
watching the deviation. As a rule, the inwarr! devia- 
tion that can be remedied by a tenotomy of the internal 
rectus is greater than the outward deviation that can 
be overcome by a tenotomy of the external rectus; 
and the effect of the former operation tends to increase 
for a certain time after its performance, while the 
effect of the latter rather tends to diminish. 

To perform tenotomy of one of the recti muscles the 
instruments required are a pair of scissors with fine but 
slightly blunt points, a pair of strabismus forceps (a 
form of fixation forceps with narrow-toothed jaws), a 
strabismus hook, and a lid elevator or speculum. A 
drop of a four-per-cent. solution of cocaine is to be 
placed over the insertion of the tendon to be cut. 
This is repeated every two minutes for ten minutes. 
The lid elevator or retractor is then introduced 
beneath the upper lid and confided to the assistant, 
who may stand behind the patient, steadying the 
head against his own breast. The operator with the 
forceps seizes a fold of conjunctiva five millimeters 
back from the margin of the cornea, and over the 
tendon to be divided. With the scissors this fold 
in the conjunctiva is snii)ped so as to make an 
opening which, when stretched out, will be from 
five to eight millimeters in length. The forceps 
then drop the conjunctiva, arc introduced thro\igh 
the cut, and made to grasp the subconjunctival tis- 
sue. This is also divided freely with the scissors. 
The hook is then introduced, the point in contact 
with the sclerotic, and i)ushed under the tendon. 
The forceps are now removed and the hook depended 
upon to fix the eyeball. The points of the scis.sors are 
introduced, one beneath the tendon and close to its 
insertion, the other over the tendon and immediately 
beneath the conjunctiva. The blades being brought 
together, the tendon is divided and the hook can be 
pushed forward without hindrance to the margin of 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



the cornea. The point of the hook is then turned anfi 
the remaining part of the tendon taken up and divided 
in a similar manner. When no bands remain to 
prevent tlie hook from freely slipping forward to the 
corneal margin, it is removed and the motility of the 
eye is tested. If motion is not decidedly limited in the 
direction of the cut tendon, the hook is to be intro- 
duced again and other bands searched for and divided. 
The effect of the operation can be enhanced by 
freely dividing the subconjunctival tissue around the 
tendon. 

For advancement of the tendon of one of the recti 
muscles, there are required, in addition to the instru- 
ments used for tenotomv, fine needles and silk sutures, 
and a needle-holder. It is better to have the patient 
recumbent, and, after the use of cocaine, an incision 
is made with the scissors in the conjunctiva, parallel 
to the corneal margin, five millimeters from it and ton 
millimeters in length. The tendon is now to be iso- 
lated and raised on the hook. A needle armed with 
the silk should then be passed through one margin of 
the tendon from the outer surface toward the eyeball 
the proper distance behind tlie insertion to give the 
desired effect; and. having been drawn through, is to 
be introduced beneath the conjunctiva near the corneal 
margin opposite the middle of the tendon insertion, 
where it is to be carried for two or three millimeters 
parallel to the corneal margin in the firm scleral tissue, 
but nottlirough it. Then the needle is carried beneath 
the other edge of the tendon, and brought out opposite 
the first point of entrance, and the loops of suture 
drawn aside. The tendon is then severed at its 
insertion, and a small piece of it may be cut off if 
a decided change of the direction of the eyeball is 
desired. The suture is then tightened and tied, 
bringing the tendon forward to the desired position. 
The eye is closed and band.aged. The stitches are 
allowed to remain several days, unless it is feared 
that too great an effect will be produced. Tenotomy 
of the opposing imisclo is combined with advancement 
to produce a marked change of direction. 

Lnternl iTanx-planlation to modify the function of a 
muscle must bo planned to meet the needs of the 
particular case. The insertion of the superior rectus 
h:us been slipped back and moved toward the temporal 
side of the eyeball to correct the disturbance of ocular 
movements caused by paralysis of the superior 
oblique. The outer halves of the tendons of the 
superior rectus and the inferior rectus have been 
separated from their normal relations and attached to 
the insertion of the tendon of the external rectus, 
to relieve congenital paralysis of the last-named 
muscle. 

In a large proportion of cases, the result of operative 
interference is only an approximate correction of the 
deformity, which may sometimes be improved by the 
subsequent use of glasses, or orthoptic training. Only 
where good binocular fusion can be obtained may a 
perfect result be hoped for. 

Par.\lytic squint is a lagging behind of one eye 
when the patient attempts to look in a certain direc- 
tion; it is due to loss of power in the muscle or muscles 
which should turn the eye in that direction. 

Such palsies may arise from lesions of the muscle 
itself, of the centers governing its action, or of the 
connecting nerve tracts. I'sually they have the 
latter origin. Early, in a case of uncomplicated 
paralytic squint, movements which do not depend on 
the muscle or muscles affected may be normal; and, 
so long as no demand is made on these muscles, no 
diplopia or inconvenience results. The squint and 
diplopia appear only when the eyes are turned in a 
certain direction. In periodic comitant squint the 
squint is sometimes absent, but when present it is so 
irrespective of the direction of the object fixed; in 
paralytic strabismus the squint, is always present 
when the eyes are turned in a certain direction, and 



always absent when they are turned in another. 
.\fter paralvsis of one of the muscles has existed for 
some time, its ela.stic tension is no longer sufficient to 
balance the elastic tension of its opponent. The latter 
turns the eye toward itself, so that it cannot assume 
the normal position, even when the muscles are 
relaxed as much as po.ssible. When this occurs the 
deviation becomes more or less constant, and if some 
power of voluntary contraction be recovered by the 
paralyzed muscle, the case assumes somewhat the 
character of comitant strabismus. It is convenient to 
classify paralytic straliismus by the nervous supply of 
the muscles involved. 

Paralysis of the ahducens nerve, or external rectus 
muscle, causes a most frequent and simple form of 
paral\i;ic squint. Strabismus occurs when the patient 
tries to look toward the side on which the affected 
muscle is situated. If the paralysis be complete, 
diplopia begins as soon as the object fixed passes the 
median line; if it be but partial, it may not appear 
until the eyes have been directed somewhat toward 
the affected side. Congenital paralysis of both of the 
abducens nerves, causing a constant convergent squint 
with inability to turn the eyes to either side, has been 
occasionallv observed. 

Paralysis of the Pntheticus, Fourth Nerve; the Superior 
Oblique Mtis'cle. — The deviation and diplopia appear 
mainly when the eyes are turned toward the affected 
side and downward. The false image is lower, and 
appears so inclined that its upper end is close to the 
upper end of the true image. 

Oculomotor Paralysis. — The involvement of all the 
extraocular branches causes drooping of the lid 
(ptosis), and leaves the eye unable to move in any 
direction except outward and a little downward. On 
attempting to look toward the sound side, or upward 
or far downward, deviation and diplopia appear, and 
increase pari passu with the effort to turn the visual 
a.xes in either of these directions. The same thing 
occurs when any attempt is made to converge for a 
near object. According to the movements attempted 
does the squint assume more the character of a diver- 
gent or a vertical strabismus. 

When the affected eye participates in the act of 
vision there is experienced a great uncertainty as to the 
position of objects, which amounts to a kind of vertigo. 
If the palsy has lasted more than a few days, a 
constant outward deviation of the visual axis is usually 
established. Oculomotor palsy may involve only a 
part of the muscles supplied by tlie nerve; or may 
even be limited to a single muscle, or a single set of 
movements. 

Recurrent attacks of oculomotor paralysis, usually 
attended with intense headache, maj- occur. The 
earlier attacks are followed by recovery, but later the 
paralvsis becomes permanent. 

Ophthalmoplegia externa is the term applied to a 
paralvsis of all the muscles attached to the eyeball. 

Treatment of Paralytic Squint. — The largest number 
of these palsies come from some syphilitic new growth, 
involving the sheath of the nerve or adjoining struc- 
tures, or from syphilitic disease of the nerve itself. 
.\ few come from disease in the course of the nerve 
trunk, and a considerable number arise from a focus of 
disease in cerebrospinal or spinal sclerosis. If there is 
a clear history of rheumatism, or collateral evidence 
of the rheumatic nature of the attack, or indications of 
gastrointestinal autointoxication, appropriate remedies 
should be carefully tried. But in other cases it is 
best to assume that the lesion is s\^3hilitic, and to treat 
it with mercury and increasing doses of potassium 
iodide until there is improvement, or until symptoms 
of iodism appear. Salvarsan has seemed to produce 
palsies of the ocular muscles; but these same attacks 
of ocular nerve paralysis have been cured by repeating 
the dose of salvarsan, or treating with mercury or 
iodides. 

It is scarcely practicable to pass through the 



I 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



Stramonium 



affected muscles electric currents powerful enough to 
have much effect on them, without endangering the 
optic nerve and retina. 

Prisms and tenotomy are not generally of any use. 
Where the deformity is very great, cosmetic improve- 
ment may sometimes be obtained by making an ad- 
vancement of the tendon of the paralyzed muscle and 
the neighboring portion of the capsule of Tenon, with 
a tenotomy or exsection of the opponent. The im- 
mediate effect, obtained in this way, should be a 
deviation toward the paralyzed muscle. For bad 
chronic cases lateral transplantation of tendon inser- 
tions should be considcrefl and tried. In cases of in- 
complete recovery passive motion has been used with 
apparent benefit. Cocaine having been applied to 
the eye, the insertion of the paralyzed muscle is .seized 
with the fixation forceps and the eyeball dragged back 
and forth in the direction in which the muscle would 
act. so that the muscle is alternately .stretched and 
relaxed to its utmost. This is continued for about 
two minutes, and repeated every two or three days. 

HF,TEnopHORi.\ OR L.\TEXT Squixt. — The perfect 
coordination of the movements of the two eyes, 
called nrthophoria, is only effected by the demand for 
single vision. In a majority of persons the with- 
drawal of the influence of binocular fusion leaves a 
perceptible squint. Such squint is called latent or 
dynamic, or is spoken of as an insuficicncij of the 
weaker of the opposed muscles, or as hrlomphnrin. 
a tending of the visual axes toward different points. 
If not great, the latent deviation will cause no trouble 
to a person with a well-developed musculonervous 
system. But in persons of inferior development and 
small reserve of nerve force, even moderate degrees of 
insufficiency may give rise to the symptoms of eye 
strain, especially if the eyes are required to do large 
amounts of work, or to work under unfavorable 
conditions. 

Diagnosis of Hcterophoria. — On covering one eye so 
that it can no longer take part in binocular vision, if 
there is heterophoria the excluded eye will deviate. 
Upon uncovering the eye, it quicklj' assumes again 
the position in which its visual axis will pass through 
the point fixed. In this way, b^' repeated trials and 
close watching of the eyes, quite low degrees of latent 
squint can be detected. The Maddox rod test is still 
more delicate. A glass rod held before one eye causes 
a distant point of light to appear as a streak. If 
this streak seems to go directly across the light as 
seen by the other eye, orthophoria is present. If the 
.streak does not cross the light, heterophoria is present. 
and the direction in which the streak is displaced tells 
the variety of heterophoria. 



o 



* 



o 



o 



o 



o 



Fio. 4094. — Di.igran. for Testing the Muscle Balance. 

To test the muscle balance at a near point a dot or 
figure, like that shown in Fig. 4694, is viewed througli 
a ten-degree prism with its base up. causing a vertical 
diplopia. If the balance be perfect, the false image 
will be exactly below the true one, as in 1, otherwise 
the false image will be displaced to the right or left. 
With the prism before the right eye, 2 will indicate 
esophoria, and 3. exophoria. 

Vnrirlies of Heterophoria. — Exophoria, or insuffi- 
ciency of the interni, occurs with high myopia, and 
from excessive near work, or as an inherent deficiency 
of convergence power. Esophoria, excessive tendency 
to convergence, is more often seen in hyperopes. but 
not exclusivelv. Hyperphoria, or vertical insuffi- 
cienc}', generally goes with one of the other varieties. 



It is right or left, according to the eye which tends to 
turn higher than its fellow. 

Either of the above may cause headache, a "drawn 
feeling about the eyes," or other symptoms of eye 
strain. But such sjinptoms should not be ascribed 
to this cause until errors of refraction have been 
accurately corrected. 

Treatment. — All remedial measures for squint may 
be resorted to. On account of the lesser extent of the 
deviation, prisms are particularly available. On the 
same account tenotomy and advancement require 
more accurate and delicate adjustment to the needs 
of the case, and are to be resorted to only after a 
thorough and prolonged acquaintance with those 
needs. Reduction of the amount of trying eyework, 
and hygienic measures calculated to improve the 
condition of the nervous system generally, are of the 
utmost importance in such cases. 

Mixed Forms of Squint. — While nearly aU cases of 
strabismus are readily referred to one or the other of 
the foregoing classes, and while it is of the first im- 
portance to have clear conceptions as to the special 
characteristics of each class, it should not be forgotten 
that many cases present the peculiar features of more 
than one class. In strabismus, therefore, each case is a 
subject for individual study. 

Edw.\rd J.\ckson'. 

BlBLIOGRAPHT- 

Duane. A.: Congenital De\'iations of the Eyes. Tr. Amer. 
Ophth. Soc, vol. xii.. p. 981. 

Hansell and Reber: The Ocular Muscles. Second edition. 
Philadelphia, 1912. 

Howe. L.: The Muscles of the Eve. Two volumes. New York, 
1908. 

Jackson. E-: Operations on the Extrinsic or Orbital Muscles. 
Wood's System of Ophthalmic Operations, vol. i., p. 649. 

Maddox. E. E.: Tests and Studies of the Ocular Muscles. 
Second edition. London. 1908. 

Motais: Anatomic de L*Appareil Monteur de L'Oeil. Paris. 
1887. 

Motais: Ophthalmic Year Book. vols. i.. 1904. to x., 1914. 

Savage. G. C. : Ophthalmic Myology. Second edition. Nash- 
ville, 1913. 

W'orth, C: Squint; Its Causes, Pathology and Treatment. 
Third edition. London, 1907. 



Stramonium. — .I.\mestown- Weed; Jim.fon Weed, 
V. S. The dried leaves of Datura stramonium L. 
or of D. tatulah. {(am. Solanaceo'). without admi.xture 
of more than ten per cent, of stems and other foreign 
matter and yielding not less than 0.25 per cent, of the 
mydriatic alkaloids of stramonium. 

The plants yielding these leaves are known as Thorn- 
apple, Apple of Peru, Stinkireed, etc. The stramonium 
plants are probably natives of southern Asia but 
have become abundantly naturalized in nearly all 
subtropical and temperate regions. They are very 
common in rich soil of waste places in the eastern 
United States. D. stramonium, which is much more 
common and abundant, and constitutes practically 
all of the drug, is a coarse, smooth annual, from one 
to six feet high, with an upright tri- and dichoto- 
mously branched, smooth, green, more or less hollow 
stem, branching at, say, a foot from the ground, and 
forming a spreading crown. The habit of the flower- 
ing and fruiting branches, and the structure of the 
large, white, fragrant flowers, and of the fruit, are 
shown in the accompanying illustrations. 

Descripttox. — The Leaves. — k much-wrinkled, deep 
or somewhat grayish-green, rarely very slightly brown- 
ish mass, consisting of petioled leaves, the blades from 
twelve to twenty-five centimeters (five to ten inches) 
limg, and about two-thirds as broad, inequilaterally 
ovate, very oblique at the base, acuminate and acute 
at the apex, very coarsely dentate or sublobed, the 
large teeth few, acute, with rounded sinuses, thin, 
smooth; the principal veins few and coarse; odor 



Stranionlum 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



slight, narcotic when bruised; taste bitter and dis- 
agreeable. 

The Seeds have also been considerably used and 
were formerly official as Stramonii Semen. They 
arc about 3.5 inillimetors (one-eighth inch) long and 
two-thirds as broad, flattened reniform, the hilum at 
one .side of the concavity; testa dull black or blacki.sh, 
hard, coarsely and shallowly reticulate-wrinkled, and 
very finely pitted; perisperm whitish, oily, concealing 
a cylindrical, curved embryo; odor unpleasant when 
bruised; taste sweetish and bitter, then somewhat 
acrid. 

Constituents. — The relations to one another of the 
mydriatic alkaloids of the Solanacea are only now be- 
coming known, and our ideas of those of stramonium 
mu.st still be regarded .as merely tentative. The alka- 
loidal content, at first described as distinct, under the 
name "Daturine," is now regarded, doubtless cor- 
rectly, as being largeh' one of the hyosc yam hies (see 
Scopoln), but which one, and in what proportions. 
and how far, and under what conditions mixed with 
atropine, are matters largely of conjecture. Even 
the percentage of total alkaloid is not well known. 
The leaves contain a large amount of ash (fourteen 
and one-half per cent.), niter, asparagin, a trace of 
volatile oil, and other unimportant sub.stances, and 
the seeds about twenty-five per cent, of fixed oil. 

The active constituents of I). Intiila are more pow'er- 
ful than those of the former and their therapeutical 
effects are not the same. It was a great mistake to 
include both under one definition. 

Action and I'sb. — From the above analysis it w'ill 
be seen that stramonium can exhibit but little dif- 
ference in action from hyoscyamus, and but little 
from belladonna. It is indeed capable of being used 
for exactly the same purposes, only it is more quiet- 
ing and hypnotic than the latter, w-hich may indicate 
the presence in it of some hyoscine or other alkaloid 
distinct from atropine or hyoscyamine. Custom, 
perhaps, as much as anything, has directed the leaves 
of this species, instead of tho.se of the others named, 
to be used in the local antispasmodic treatment of 
asthma, for which purpose it is almost entirely pre- 
scribed. The common method is to administer it by 
smoking. The leaves may bo burnt in a pipe or on 
the cover of a hot stove, or they may be made more 
inflammable by being soaked in a strong solution of 
saltpeter and dried, after which they will burn steadily, 
without flame and without reciuiring any apparatus; 
prepared in this way and flavored with aromatics 
and balsams, they are the foundation of most of the 
"asthma cigarettes" and "pastils," which are often 
better products than extemporaneous preparations 
are apt to be. The French Codex gives directions 
for making cigarettes of stramonium, containing one 
gram each of leaves, without any admixture. For 
internal administrationstramonium may be considered 
as about the equivalent of hyoscyamus. The prepa- 
rations, formerly official, were all made from the seed, 
the leaves being used only for smoking. At present 
the seeds are not official. The following official prepa- 
rations are made from the leaves: Extract (Extrnc- 
tum Slratnnnii), strength about }; Fluid Extract (Fluid- 
exlrnrlum Siramnnii), strength, \; Tincture iTinclura 
Slramonii), .strength X and the Ointment {Ungnentum 
.Sframonti), strength (^of the extract), ^^ in benzoinated 
lard. All these have similar properties and u.ses to the 
corresponding preparations of hyoscyamus and bella- 
donna, but are more hvpnotic than the latter. Dose 
of extract, gr. |-i (0.008-0.01.5); of the fluid extract 
njii-ij (0.06-0.12); of the tincture irijv-xv (0.03-1.0). 

Allied Plants. — Datura consists of a dozen, 
mostly large, rank herbs, most of which have similar 
medical properties to the above, although not identical. 
Henry H. Rusby. 



Strieker, Salomon. — Born at Waag-Neustadth, 
Hungary, in 1834. After studying law for a short 
time he turned his attention to medicine, and re- 
ceived his doctor's degree from the University of 
Vienna in 18.58. In 1S03 he became an Assistant in 
Bruecke's Institute of Ph3'siology. In 1865 he 
I)ublished his first reports on the diapedesis of the 
red blood corpuscles and the contractility of the walls 
of blood-vessels. In 1868, at Prof. Rokitansky's 
suggestion, he was made Professor Extraordinary of 
Experimental Pathology and Director of an institute 
which was established for the express purpo.se of 
facilitating his and his pupils' researches. In 1872 
he was made regular Professor of General and Experi- 
mental Pathology. He died April 2, 1898. 

Strieker and his pupils are to be credited with a 
number of important discoveries — as, for example, 
certain new facts relating to the histology of the 
cornea; the mechanism of secretion in glands; the 
division of cells in living tissues; the doctrine of the 
relation of cells to ground substance; the vasomotor 
center for the abdominal organs; the vasodilator nerve 
fibers in the sensory roots of the sciatic nerve; the 
origins of the nervi accelerant es; the modus operandi 
of diuretics; the anesthetic effects of cocaine; etc. 

Of Strieker's published writings the following 
deserve to receive special mention: "Handbuch der 
Lehre von den Geweben des Menschen und der 
Thiere" (written conjointly by Strieker and other dis- 
tinguished histologists), 1871-73; "Vorlesungen ueber 
allgemeine und experimentelle Pathologie," 1877-83; 
"Studien ueber das Bewusstsein," 1879; "Ueber die 
Bewegungsvorstellungen," 1882; and "Studien ueber 
die Association der Vorstellungen," 1883. 

A. H. B. 



Stromeyer, Georg Friedrich Louis. — Born at 
Hannover, Germany, March 1, J 804. He studied 
medicine at the School of Surgery in Hannover, and 
also at the Universities of Goettingen and Berlin, 
from the latter of which institutions he received his 
doctor's degree in 1826. In 1829 he established an 
Orthopedic Institute in his native city, and also began 
to give instruction at the School of Surgery. Nine 
years later (in 1838) he was given the Chair of Surgery 
in the High School of Erlangen. Then he served in 
the same capacity at the following universities: 
Munich, 1841; Freiburg, 1842; and Kiel, 1848. In 
the campaigns of 1849 and 18.50 he rendered valuable 
professional services to the Schleswig-Holstein Army; 
and again in the years 1866 and 1870 he rendered 
equally valuable services to the Hannoverian Armv 
(1866) and the German Army (1870). He died 
June 15, 1876. 

Stromeyer ranks as one of the greatest military 
surgeons, not merely of modern but also of all times. 
Aside from this, he will always be remembered for 
having introduced into surgery, as one of its perma- 
nently useful possessions, the operations of subcuta- 
neous myotomy and subcutaneous tenotomy. The 
first time he performed the latter operation (on the 
tendo .\chillis) was on Feb. 28, 1813 (Jaeciues Del- 
pech, having already performed the same operation 
at Montpellier, France, in 1806). After the lapse 
of twenty-three years (in 1836) Stromeyer repeated 
the operation in the case of a j-oung English physician 
(Dr. Little) who was affected with pes equinovarus, 
and who had alreadj- been told by Dieffenbach that 
he could do nothing to relieve him of his deformity. 
Subsequently, when Dieffenbach learned how com- 
pletely successful the tenotomy had been, he became 
an enthusiastic advocate of the operation, and was 
thus the cause of its being generally adopted bj' sur- 
geons in every part of the world. It would seem, 
therefore, as if, in the apportionment of the degrees 
of credit due to these tw^o men (Delpech and Stro- 
meyer) for the different parts which they took in the 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



Strophantbng 



discovery and introduction of subcutaneous tenotomy, 
the larger share belonged rightly to Stromeyer. 

Of the latter's published writings the following 
deserve to receive special mention: "Maxinien der 
Kriegsheilkunst," Hannover, 18.55 (second edition, 
1862); "Handbuch der Chirurgie," 2 vols., 1844-50; 
"Erfahrungen neber Sehusswunden im Jahre 1866" 
(Supplementary to hus Maiimen, etc.), Hannover; 
and "Ueber die Durchschneidung der Achilles.sehne," 
in Rxisl's Magazine, 1833. A. H. B. 



Strongylidae. — A family of round worms. The 
body is cylindroid or rarely filiform; the mouth usu- 
ally has six papillse; esophagus more or less enlarged 
posteriorly. The male has an enlarged bursa copu- 
latrix and one or two spicules. The female has a 
.single or double ovary. The family contains a 
number of genera. The hook-worms are important 
representatives. See Xematoda. A. S. P. 



Strongyloides. — A genus of round worms. S. 
intestinalis is a minute parasite which lays eggs in 
the mucosa of the small intestine of man. The 
eggs hatch into small larva; which pass out with the 
feces and develop in water into male and female 
forms. These conjugate and eggs are produced 
which give rise to rhabditiform larvae and these 
after molting reinfect man through the skin. See 
Nematoda. A. S. P. 



Strongylus. — A genus of round worms in which 
the mouth may be nude or provided with papillje; 
esophagus dilated posteriorly; male with bursa 
copulatrix; females with ulva in posterior half of 
body. S. gibsoni was discovered in the feces of a 
Chinaman in Hong Kong. See Nematoda. 

A. S. P. 



Strontium. — General Medicinal Properties of Com- 
pounds of Strontium. — Salts of strontium resemble 
those of calcium in being practically non-poisonous 
to the human system and in tending to improve nutri- 
tion. Also they are of low diffusion power, and 
accordingly are comparatively slow of absorption. 
Strontium has been proposed in medicine as affording 
a base for medicinal salts that is non-poisonous and 
even agreeable to the stomach. Accordingly stron- 
tium has been suggested for the basic carrier of bro- 
mine, iodine, and salicylic acid, and the bromide, 
iodide, and salicylate of the metal are considerad 
preferable to the corresponding potassium and 
sodium .salts, because better borne by the .stomach. 
The United States Pharmacopoeia recognizes stron- 
tium bromide, iodide, and salicylate (see Bromides, 
Iodides, and Salicylates); and formerly also the lactate, 
which latter salt will be considered here since its 
effects are not due specifically to its acid radical. 

Stroiiliinn Lactate. — The salt was formerly official 
in the United States Pharmacopcria under the title 
Strontii Lactns, Strontium Lactate. It occurs as a 
white, granular powder, permanent in the air. It 
is odorless, with a bitterish, salty taste. It dissolves 
in about four parts of cold water, and freely in boiling 
water and in alcohol. Strontium lactate is a harmless 
salt, whose use in medicine is because of a reputation, 
in chronic Bright 's disease, for diminishing the 
albumin in the urine and improving the patient's 
condition generally. In the form of the di.sease 
accompanying rheumatism and gout, it is praised, 
but it should not be used in conditions of acute in- 
flammation with high fever. In albuminuria from 
heart disease, also, the medicine is reported to 
diminish the albumin. The drug may be given in 



doses of from gr. xx. to xxx. (1.. 3-2.0) or more, two or 
three times daily. Edward Ccrtis. 

R. J. E. Scott. 



Strophanthus. — {Komh& Arrow Poison, InSe, 
Onaye, etc.) The dried ripe seed of Strophanthus 
kombe Oliver, or of .S. hispidus DC. (fam. Apo- 
cynacetr), deprived of its long awn. The British 
Pharmacopoeia names S. komhe, under the title 
Strophanthi Semina. The German, under the title 
Semen Strophanthi, says "very probably from Stro- 
phanthus kombe." The United States Pharmacopoeia, 
because at the time of its revision ten years ago in- 
formation on this point was verj- imperfect, specified 
the seeds of S. hispidus De C. Clinical experience 
indicated that they were nearly worthless, and they 
were dropped from the edition of 1900. In the pres- 
ent edition, they are again introduced, as the equiva- 
lent of the others. This action rests upon the fact 
that when administered to cats, the latter are killed 
as quickly as by those of S. kombe, or even more so, 
and upon the assumption that the cat-killing action 
is that desired in therapeutics; although this may be 
true, present evidence is to the contrary. 

The strophanthus plants are woody climbers of 
tropical .Africa, where an extract of the seeds of several 
of them is used as an arrow poison and in other ways 
for poisoning. The seeds occur in lanceolate or lance- 
ovoid follicles, of which two develop from each flower. 
These are fifteen to thirty centimeters (six to twelve 
inches) long, and about a sixth or a fifth as thick. 
They are densely filled with seeds, the, bodies of which 
are embedded among the long, white plumose awns. 
The seeds are imported either in the pods or aftef re- 
moval, and in the latter case either with or freed from 
their awns. They should be imported and reach the 
consumer in the pods, since this permits the identifica- 
tion of the contents by the testing of one seed from 
aach pod. This is an almost necessary method of ex- 
cmination, since good and poor varieties ol seeds so 
loosely resemble one another that an admLxture is 
very difficult to detect in the cleaned seeds. Some 
varieties are practically inert, while others are ex- 
tremely powerful, and indifferent ways, so that the em- 
ployment of correct methods of identification of the 
seeds is of vital importance to the patient. .Although 
all parts of the plant are bitter, the seeds alone have 
been investigated. 

Description. — Good strophanthus seeds (those of 
S. kombe) are of a peculiar pale greenish-brown color, 
and are densely covered with very fine, closely ap- 
pressed silky hairs. This appearance of the sur- 
face constitutes the best guide to selection, outside 
of chemical examination. Those of iS. hispidus are 
of a reddish-brown color. Those of a spurious va- 
riety are of a very pale yellowish or yellowish white, 
without greenish tinge, and the hairs coarse and 
more or less roughening the surface by their irregular 
projection. Strophanthus seeds are about 1.25 
centimeters or a little more in length, and one-fourth 
to one-third as thick, lanceolate, obtuse at the base, 
gradually pointed at the summit; they are somewhat 
flattened or even a little hoUowish on one side, and 
have a narrow ridge running along the other, and are 
often warped or even semi-twisted. They are brittle, 
the fracture whitish and oily, the kernel consisting 
of rather long cotyledons, enclosed in sparse albumin. 
They have a slight odor and an extremely bitter 
taste. On being crushed and tested with strong 
sulphuric acid, a green color should quickly de- 
velop, due to the reaction of the strophanthin. which 
is mostly contained in the albumen or endosperm. 
In this way. the testing of a single seed taken from a 
pod deterniines the identity and quality of the entire 
contents. However, should the test fail, it should be 
repeated with one or two more seeds from other 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



parts of tlie pod, as individual seeds sometimes occur 
whidi are imperfect. 

CoNSTiTTENTS. — With various Ordinary constituents 
of seeds, stroplianthus contains two or tlirce bodies of 
therapeutical interest. The important mediciiuil 
constituent is two to three per cent, of strophanthin, 
consiilored below. The properties of the twenty-five 
to tliirtv per cent, of fixed oil are not known with 
certainty. We should expect it to be inert, but in- 
dications of its irritating and toxic properties are not 
wanting. On the other hand, these are more lilcely 
due to contained substances than to the oil itself. 
Some species of the seeds contain the very poisonous 
glucosidc jiseudo-slTophdnthin, and, since the com- 
mercial seeds are almost always mixed, it may be the 
presence of this in the oil which makes the latter 
poisonous. The poisonous properties referred to 
are not the same as those of overdoses of strophan- 
thin, since the greater toxicity is not accompanied by 
a correspondingly greater cardiac tonic elTect, but 
often by a lesser one. Kombic acid is present, but its 
properties have not been investigated, and the name 
has apparently been applied to more than one sub- 
stance. Other constituents reported arc uncertain, 
since the specific identity and freedom from admixture 
of the seeds analyzed has not been determined. 
Stroithanthin is a crystalline glucoside, usually ap- 
pearing amorphous, as a fine white powder, soluble 
in alcohol and water, especially the latter, insoluble 
in ether and chloroform. The fornuila usually given 
(C3iH,80i;) cannot be considered as fully established. 
i'pon decomposition, it yields stroplianlhirlin. Com- 
mercial stroplianthin is very rarely, if ever, pure. 

.\rTiox .\XD U.sEs. — The therapeutical action of 
strophanthus is that of strophanthin, and is directly 
and almost wholly referable to the heart. It is com- 
monly .stated as Vieing identical with digitalis, but the 
statement is very misleading, unless certain dif- 
ferences in other directions are carefully considered. 
.Vlthiiugh its direct action is almost identical with 
that of digitalis, the resultant effect is quite different, 
owing to the absence of those complications from 
arterial effects which result from the use of digitalis. 
Strophanthus does not greatly contract the arteries, 
hence little of the gain from cardiac stimulus is coun- 
teracted, and there is none of that danger of damming 
back the lilood upon an incompetent heart, which 
sometimes exists when digitalis is used. Another very 
important dilTerence between the two is the great 
promptness with which strophanthus gets to work, its 
efTeits being ob.served in from a third to a half of the 
time required for digitalis. This is partly due to its 
purely cardiac action, partly to the fact that the ab- 
sorption of strophanthin is very rapid. Strophantluis 
strengthens and slows the heart beat, prolonging the 
diastolic period, and it is especially valued for its 
power of restoring rhythm to an irregular be.at. It is 
thus especially useful when a very prompt action is 
desired, and also where cardiac action is weak rela- 
tively to arterial. Even in those cases in which 
digitalis is properly called for, a great gain may be 
secured by giving an initial dose of strophanthus, 
following it with the digitalis. 

On the other hand, the effect of strophanthus is far 
less prolonged than that of digitalis, and is not 
cumulative like the latter. Hence, small doses, re- 
peated at frequent intervals, is the rule for the ad- 
ministration of strophanthus. Even in this way its 
effects cannot be prolonged like those of digitalis, for 
the beneficial effects fir.st seen soon decrease. It 
cannot therefore be regarded, like digitalis, as a 
mainstay, but rather as an emergency remedy. 
The elTect upon the stomach is far less irritating thiin 
that of digitalis, hence there is not the same tendency 
to emesis. The same principle applies to the kidney.s, 
the local effect upon the latter being very slight. 
Yet strophanthus is an indirect diuretic, through 



increased cardiac action. It is often even more 
strongly diuretic than digitalis, owing probably to the 
absence of obstruction by vascular contraction. 
For the same reason, the danger of damage in case.? 
of complication with organic kidney disease is want- 
ing. Strophanthus is also a safer and more com- 
fortable remedy for children. 

Administration. — Owing to the facts stated above. 
it is not so difficult to secure genuine and pure 
strophanthus seeds, and therefore correspondim; 
preparations of them, as it is to secure pure stroph- 
anthin, and the former are to be preferred in all 
ordinary cases. The official preparation is a five- 
per-cent. tincture of the seeds, made with sixty-five- 
per-cent. alcohol, and the dose ranges from three to 
ten minims (0.. 5-0.(5). When larger doses are re- 
quired, it is usually because the very inferior "brown 
seeds" have been employed. These are several times 
cheaper and they ha\e been used extensively even b.\- 
some large manufacturers. On the other hand, a 
preparation of the "white seeds" will prove irritating 
and will act as a poison without a corresponding in- 
crease in therapeutic effect. Strophanthin mav be 
given in doses of sic-yb (0.0003-0.0006). 

Henry H. Rusny. 



Struma. — This term has been used in a general 
way to indicate a swelling or protuberance in any part 
of the body, but particularly with reference to enlarge- 
ments of the lymph glands and the thyroid gland. 
Since such enlargements are most frequently due in 
the case of the lymph glands to tuberculosis, and in 
the thyroid to goiter, the word struma has come to be 
largely used as a synonym for both scrofula and 
goiter. Further, it has been applied to enlargements 
of the lymph glands other than those of a tuberculous 
nature, also to enlargements of the thymus, to en- 
largements of the kidneys and suprarenal bodies dui- 
to tumors arising from adrenal tissue, and in rarr 
cases to splenic enlargement. Such a widespread 
application of the term, as well as its failure to convey 
any definite idea concerning the etiology or patho- 
logical nature of the conditions so designated, would 
appear to be sufficient reason for its abandonment, and 
in pathology it is gradually falling out of use. 

Aldred Scott Warthin. 



Strychnine.— .S/ri/r/mJ/ia (Ci.HsjNiOi = 333.31). 
"An alkaloid obtained from nux vomica, and also 
obtainable from other plants of the family Logani- 
acece." — U. S. P. 

The origin of strychnine has been fully discussed 
under Nux Vo})iica. Its extraction from the seed is 
accompanied by much difficulty, owing to its strong 
retention in tlie cells of the horny albumin. Natu- 
rally, various methods have been employed for over- 
coming this difficulty. The seeds are either powdered 
in their original condition, or first subjected to a 
steaming process and then dried. The strj'chnine 
can be dissolved out by alcohol in the form of its 
natural salt or by water acidulated with hydrochloric 
acid. The concentrated and filtered solution is then 
treated with an alkali, such as acetate of lead or lime, 
to decompose the alk.aloid, which is then precipitated 
and purified. The principal impurity liable to exist 
is brucine, the tests for which are indicated in the 
following description: 

Colorless, transparent, octahedral or prismatic 
crystals, or a white, crystalline powder, odorless, and 
having an intensely bitter taste, perceptible even in 
highly dilute (1 in 700,000) solution. Permanent 
in the air. 

Soluble, at 1.5° C. (.59° F.), in 6,700 parts of water 
and in 110 parts of alcohol; in 2,500 parts of boilins 
water and in 12 parts of boiling alcohol. Also soluble 
in 7 parts of chloroform, but almost insoluble in ether 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



Strychnine, Poisoning by 



When heated to 268° C. (514.4" F.) strychnine melts. 
Upon ignition it is consumed, leaving no residue. 

Strychnine has an alkaline reaction upon litmus 
paper. 

If a minute quantity of strychnine be dissolved in 
about 0.5 c.c. of concentrated sulphuric acid on a white 
porcelain surface, and a small crystal of potassium 
dichromate slowly drawn across the liquid with a glass 
rod, there will be produced at first, momentarily, a 
blue color, which quickly changes to purplish bkie, 
then gradually to violet, purplish red, and cherry 
red, and finally to orange or yellow. 

On dissolving 0.02 gram of strychnine in 2 c.c. of 
nitric acid (specific gravity 1.300), in a small test-tube, 
the acid should not turn more than faintly yellow 
(limit of brucine). 

Action and Uses. — Strychnine is one of the most 
intense and energetic of poLsons, acting deleteriously 
upon nearly all forms of animal and vegetable life. 
There are, however, considerable differences in the 
susceptibility of different creatures to its influence, 
and in general those which are destitute of or have but a 
primitive nervous system withstand it better than the 
higher organisms. Its antiseptic and antizymotic 
properties, though distinct, are decidedly weaker than 
those of quinine and some similar substances; for this 
reason and because of their being but a little poison- 
ous, the latter are far more desirable of employment 
for such purposes. 

AbsoT ption and Elimination. — Strychnine is 
promptly absorbed from the mucous membrane and 
rather freely from abraded surfaces and from the 
subcutaneous tissue. It circulates in the blood as 
strychnine and is thus eliminated, though a small part 
of it is oxidized. Elimination is principally by the 
kidneys, to a considerable extent through the saliva, 
and to a slight extent through most of the other 
channels. This prompt absorption and slow elimina- 
tion render it one of the most notoriously cumulative 
drugs. Tolerance, by its continued use, is not much 
increased. 

Local Action. — The disinfectant properties of strych- 
nine is noticed above. It exerts a prompt though 
mild stimulant action upon the tissues with which it 
comes into contact. In the mouth and stomach it 
acts like the ordinary simple bitters, in promoting 
the appetite, but, unlike the most of them, its presence 
in the stomach promotes rather than inhibits diges- 
tion, so that it is probably the most valuable of all 
stomachic bitters, especialiy in view of the fact that 
its local effects are strongly reinforced as soon as ab- 
sorption begins. In the intestine, its local effect is 
to stimulate peristalsis, making it a valuable laxative, 
and this effect is again reinforced by its systemic action 
through the spinal centers. 

Upon the heart the operation is somewhat different, 
since the local effect of stimulating the rate, through 
its action on the muscle, is just about counteracted by 
its systemic effect upon the vagus centers, which 
checks such increase. 

Systemic Action. — The effects of strychnine upon all 
the bodily systems are to be understood by regarding 
it as a direct and pure stimulant, its action upon the 
motor centers of tlie cord, and to a lesser extent upon 
those of the brain, vastly predominating. Thus it 
stimulates the circulation (the vagal effect having 
been considered above), both through the heart and 
through tlie vasomotor system, promptly and strongly 
increasing blood pressure; it powerfully stinuilates the 
respiration, increasing both the rate and the strength 
of the respiration; it increases metabolism and waste 
and raises the temperature moderately; it increases 
the activity of all* muscular tissue, both voluntary and 
involuntary, partly, as already stated, bj' direct ac- 
tion, increasing excitability, but to a far greater ex- 
tent through stimulation of the motor centers. Thus, 
sligliter stimuli are required to set the movements 



going, and the movements themselves exhibit in- 
creased strength. All the special senses are sharpened, 
especially that of sight, and this more particularly 
for blue colors. All of these effects are more fully 
described in the article on Strychnine, Poisoning by, 
which account will serve also to explain the reverse 
symptoms, occurring as after-effects in that condi- 
tion. 

Therapeutic Uses. — The very numerous therapeu- 
tic uses for strychnine may. for the most part, be in- 
ferred from what has preceded. It can be employed 
to stimulate almost any of the lagging vital powers. 
It is so emplojed, most largely perhaps, in promot- 
ing the functions in the aged. It is also very valuable 
in the stimulation of those persons whose habits of 
life are unnatural, in that they do not take sufficient 
exercise or perform other ordinary hygienic duties. If 
careful attention be given to the patient, the most 
valuable effects can he secured from strychnine by 
utilizing its action as an aid in inducing the indolent 
to take needed exercise while under its influence. 
While it cannot be relied upon for overcoming a con- 
dition of chronic constipation, it becomes, in connec- 
tion with other drugs, a most valuable aid in this direc- 
tion. Its uterine stimulation cannot be overlooked, 
either from the standpoint of undesirable effects or 
from that of desirable effects. It is a pronounced 
aphrodisiac. In rendering cardiac support in such 
exhausting diseases as pneumonia, it is of the utmost 
value. Its value as a tonic in all ordinary forms of 
impaired digestion has been indicated above. 

Although these beneficial effects from the use of 
strychnine are almost marvellous, it is to be re- 
membered that, since its action is purely stimulat- 
ing, it can easily be so used as to result in the most 
damaging way. It must never be relied upon to take 
the place of natural powers and conditions, but should 
always be considered as a means of inducing their 
activity. Otherwise the system can easily become 
exhausted, a condition of depression made to follow 
that of stimulation, it being then found extremely 
difficult to discover any other means for again 
stimulating them. 

Compounds, Prepar.\tions, and Doses. — Strych- 
nine, because of its high insolubility, is rarely used 
except in the form of its salts, of which the sulphate 
is official. It occvirs in intensely bitter, white, pris- 
matic crystals, which effloresce in the atmosphere. 
It is soluble in fifty parts of water, and in 109 parts of 
alcohol, but is nearlv insoluble in ether. The dose 
of strychnine itself is gr. ^r, to .'i, (0.001 to 0.006). 
Strj-chnine is combined in many popular formula? with 
the hjrpophosphites, and with iron, quinine, and other 
tonics. Two such are official: the citrate of iron and 
quinine (ferri et strychninse citras), containing one per 
cent, each of strychnine and citric acid, with ninety- 
eight per cent, of iron and ammonium citrate, the dose 
gr. i to iij (0.0(5-0.2); and the syrup of the phos- 
phates of iron, quinine, and strychnine (syrupus ferri, 
quininoc et strychnine phos])hatum), containing 0.02 
per cent, of strychnine, two per cent, of soluble ferric 
phosphate, three per cent, of quinine sulphate, 4.8 per 
cent, of phosphoric acid, ten per cent, of glycerin, and 
five per cent, of water, in syrup, the dose fl. 5ss-i 
(2.0-4.0). Henry H. Rusbt. 



Strychnine, Poisoning By. — Poisoning by nux 
vomica was recognized as early as the seventeenth 
century by Wepfer and Valentine. Strychnine was 
discovered by Pelleticr and Caventon in 1818, but 
Blumliardt made the first report of a death from 
strychnine poisoning in 18.37, and the first homicidal 
case was tried in Canada in 1851. 

Symptoms. — Small poisonous doses of strychnine 
practically produce much the same symptoms as large 



Stryrbnine, Poisoning by 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



doses but in lesser degree. The onset may be Rradiial 
or sudden, usually sudden, depending on the size and 
form of the dose, the susceptibility of the patient, and 
the condition of the digestive tract at the time of the 
administration of the poison. The salts of the alka- 
loids are the most readily absorbed and when taken 
on an empty stomach absorption is rai)id and symp- 
toms correspondingly so. There may be at first a 
numbness beginning" in the extremities and creeping 
over the whole bofly, ending in a stiffening of the 
muscles of the back of the neck with a constricted 
feeling in the throat. Twitching occurs, and an 
increased tension of all the muscles of the body, espe- 
cially the extensors. The head is retracted, with the 
trunk stiff and the arms and legs spread in full exten- 
sion. In severe cases this may be so intense as to 
produce opisthotonos, a condition in which the body 
is thrown out so that the back forms a curve, with 
the weight resting on the back of the head and the 
heels. Very rarely the body is drawn to the side, 
pleurothotonos, or forward, emprosthotonos. These 
tonic convulsions vary in degree, and in the very mild 
attacks may not amount to more than the severe 
muscular contractions. They may be rapidly re- 
peated, or may appear but once or twice, or not at all 
during the attack. The mind's action seems to the 
patient to be intensified and is extraordinarily clear, 
rapid, and easy, and thoughts practically race through 
the brain, while the reasoning ability asserts itself 
without any effort. This stimulated condition of the 
brain is one of the cardinal symptoms of strychnine 
poisoning. Restlessness and a feeling of depression 
together with a sensation of impending death accom- 
pany even the mild attacks. The action of all the 
special senses is intensified, especialh' the hearing — 
another diagnostic feature. The eyeballs become 
protruded, the pupils dilated, and the lower jaw is 
fixed and rigid. Since the respiratory muscles are 
affected during the spasm, air hunger occurs, with 
dryness of the mouth and throat later in the condition. 
During the early convulsions, there may be excessive 
frothy, blood-streaked saliva produced by early 
stimulation of the salivary glands together with the 
fact that the tongue may be caught between the teeth 
thus causing the i)resence of blood in the mouth. The 
face is pale and anxious and the mental anxiety in- 
creases. Even in mild cases sharp pains not unlike 
grippe pains are experienced all over the body, due to 
the intense muscular activity, and only gradually 
disappear. Clammy sweat covers the body. 

In mild cases, the tense, tonic condition of the 
muscles gradually wears away, relaxation occurs, the 
eyes and pupils become more normal, and regular 
respiration is established, but the stimulated mind 
action lasts for a much longer period. In the more 
severe attacks, the convulsions' continue and may be 
easily precipitated by the slightest sound, the jarring 
of the bed, or a draught of air. If the patient is 
warned of the occurrence of such stimuli, he will make 
an attempt to ward off the oncoming convulsion by a 
request to have his body and extremities nibbed or 
held, and many times he can give warning of the ap- 
proach of the convulsion. Recovery is comparatively 
rapid, as the active symptoms usually disappear 
within a few hours, and when the convulsions can 
be controlled and cease, the patient is practically out 
of danger, although not recovered, for even in mild 
attacks great muscular prostration may exist and 
involuntary muscular contraction continue. In fatal 
cases, the spasms continue, and death is due ordinarily 
either to asphj-xia caused by the fixation of the respira- 
tory muscles during a protracted spasm, or, more 
rarely, to exhaustion, which occurs during a relaxed 
period. In the majority of fatal cases death occurs 
during or after the fourth or fifth tetanic convulsion, 
but where the dose has been large or the patient 
exceedingly susceptible, it may take place during the 
first seizure. 

10 



.\fter death, rigor mortis may come on early, espe- 
cially if the victim has died in a convulsion. There is 
no definite certainty as to the length of time the 
rigidity may last. Authorities give the time as 
anywhere from one-half hour to five days. There 
has been found congestion of the brain and spinal 
cord, but the digestive tract shows no characteristic 
trace of the drug after death. 

Elimination of strychnine from the system is con- 
sidered by most authorities to take place through the 
urine, although a decided diversity of opinion exists. 
Dragendorff held that it is deposited in the liver for a 
lengtli of time, while Ilarley considered it to be oxi- 
dized. .'Vccording to Kratter, the drug passes through 
the body unchanged and is carried off in the urine 
within forty-eight hours after the intake. 

Poisonous Dose. — Witthaus gives } grain (0.016) 
of the sulphate of strychnine as a lethal dose, while 
Hare states that the average fatal dose for an adult is 
1^ to IJ grains (0.10 to 0.12). Recovery has occurred 
after the swallowing of 19 grains of the sulphate of 
strychnine. In children ^j grain has produccrl death, 
and sV grain has precipitated muscular twitchings. 
If the drug is given hypodermically the action is 
usually much more rapid. 

It has been demonstrated by Reichert that .500 
times the ordinarily fatal dose is required to produce 
death in animals if artificial respiration is correctly 
maintained. 

Differential Diagnosis. — The convulsions of 
strychnine poisoning are to be differentiated from 
those of tetanus, epilepsy, and hysteria, which they 
most resemble. 

In tetanus there is the history of the condition, 
usually dating shortly after an injury, however small, 
and the convulsions affect the body from the head 
down to the extremities, and the rigidity of the jaws 
is an early symptom. They increase in number a.s 
the disease progresses and the entire course is longer 
than that of strychnine poisoning; in epilepsy the 
convulsions are clonic, and the typical history of the 
condition aids; in hysteria, the story is significant, 
and the changes in skin sensibility with areas of 
hyperesthesia and anesthesia are present, but the 
spasm may strongly resemble strychnine spasm. .\s 
opposed to these in the strychnine convulsion thert- 
is the history of the dose, the usually very sudden 
onset, the clearness of the mind, and the later stiffen- 
ing of the jaw to differentiate it from the other types. 

Treatment. — Immediate action, quietly carried 
out, is the first requirement. Slight attacks of 
poisoning have been known to subside without any 
treatment other than quiet. If treatment can be 
begun before the symptoms have manifested them- 
selves, when the drug has been taken by mouth, the 
stomach should be immediately washed out by means 
of the stomach tube. As the use of the tube may bring 
on a spasm, the patient should be sufficiently chloro- 
formed to maintain relaxation of the muscles. After 
the first washings, another washing of tannic acid in a 
dilute solution (two per cent.) should be given through 
the tube. Tannic acid is the chemical antidote for 
this poisoning and forms an insoluble tannate with the 
strychnine sulphate, rendering it less soluble, and reduc- 
ing its absorptive action. Following this the physio- 
logical antidotes bromide of potassium and chloral, sixty 
grains of the first (4.0) and twenty grains (1.3) of the 
chloral in solution, are given by the tube. The bromide 
of potassium acts on the sensory tracts of the spinal 
cord, while the chloral depresses the motor tracts. 
Chloroform should be given cjuietly at the approach 
of the convulsions, and if the pat'ient is unable to 
swallow, the sedative drugs — physiological antidotes 
— may be given in starch-water by the rectum. When 
the convulsions are so severe as to produce immova- 
bility of the chest, Hare advises the hypodermic 






REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



Styrai 



injection of amyl nitrite, as then chloroform is 
of no service. Quiet and darkness of the room 
are important means in aiding the control of the 
convulsions. 

Tests. — Many tests have been formulated for the 
detection of strychnine in the tissues of the human 
body after death. Dragendorff's test is used when 
the analysis is not to be limited to a search for strych- 
nine only and a modification of this test may be u.sed 
in medicolegal cases where it is necessary to detect 
the presence or absence of strychnine in the urine 
during the life of the patient. Among other tests 
used for detecting strychnine are: (1) Strychnine 
crystallizes from an alcoholic solution in small, four- 
sided, orthorhombic prisms, terminating in four-sided 
pyramids; .sometimes all in small hexagonal plates. 
Precipitated by ammonia from solutions of its salts, 
it forms slender, needle-like, four-sided prisms. (2) 
The taste of strychnine is intensely bitter, with a 
faint metallic aftertaste. The bitter taste is still 
perceptible in a solution containing only one part of 
strychnine in two hundred thousand of water. 
Esther L. Jefferis. 



Stvpticin, is the trade-name of cotarnine hv- 
droctiloride (Ci.HuNOs.HCl.H^O), obtained by tlie 
oxidation of narcotine, an opium alkaloid; it occurs 
in bitter yellow crystals which are soluble in water 
and alcohol. The solutions slowly darken on ex- 
posure to light. Chemicallv it differs but slightly from 
hydrastinine hydrochloride (CiHi.NO^.HCl.HjO); 
and clinically it exerts a similar action on uterine 
hemorrhage. 

Falk, of the Pharmacological Institute of Berlin, 
states that it paralyzes the motor cells of the spinal 
cord, is mildly narcotic, and stimulates peristalsis. 
It has no direct effect upon the circulation and is 
depressing to respiration, death being due to respira- 
tory paralysis. 

Rous.se and Walton, Marfori, and others, however, 
assert th.at it stimulates the heart, and that it con- 
trols hemorrhage by vasoconstriction. It does not 
coagulate the blood. As to its effect on uterine con- 
traction there are conflicting statements. MacXaugh- 
ton-Jones and a few other writers believing it con- 
traindicated in pregnancy, while d'Alessandro, Beadles, 
and many other obstetricians, have found it most 
useful in threatened abortion. 

The only use of stypticin is to control hemorrhage, 
and the conditions in which it is especially indicated 
are: menorrhagia, puerperal hemorrhage, subinvolu- 
tion, climacteric hemorrhage and hemorrhage depend- 
ent upon periuterine or adnexial disease. Boldt 
recommends it highly in the profuse and irregular 
menstruation of virgins in whom there is no detectable 
pathological lesion. In hypertrophic endometritis 
and uterine fibroid it seems to act successfully in 
only a limited number of cases, though in the latter 
condition H. D. Ingraham found it better than ergot, 
hydrastis or thyroid, and MacXaughton-Joncs 
writes: "The hemorrhages in which it proves of most 
service are those due to uterine interstitial fibroid," 
. . . etc. The drug has been given with apparent 
good result in hemoptysis, hematemesis, hematu- 
ria, and the menstrual neuroses. 

The do.se is gr. H-U (0.02-0.09) several times 
a day in pearl, capsule, or solution. In menor- 
rhagia the larger dose is given for two or three days 
before the expected menstruation. The only ill 
effects noted by Goldschmidt from a dose of gr. 
J-1 (0.03-0.06) every two or three hours for a week, 
were nausea, and heaviness and constriction in the 
stomach. Where a prompt effect is desired mixxx. 
(2.0) of the ten-per-cent. solution may be administered 
hypodermatically in the gluteal region. The in- 
jection is non-irritating (d'Alessandro). 



Locally stypticin has been applied to the cavity of 
the uterus and to bleeding tooth cavities; and it is 
used in rectal hemorrhage, nosebleed, and following 
small operations. A very useful form for local 
employment is the stypticin-gauze or stypticin- 
cotton, made by soaking the gauze or cotton in a ten- 
to-fifty-per-cent. solution of stypticin and allowing 
it to dry. Stypticin has also been used in bougies 
containing half a grain each (0.03) to check bleeding 
from the urethra. W. A. Bastedo. 

R. J. E. Scott. 



Styptol (cotarnine phthalate) i.s' represented by the 
formula, (C,2H,5NO,)2C6H4l('OOH)2. It is a yellow 
cr3'stalline powder, readily soluble in water, containing 
about seventy-five per cent, of cotarnine and twenty- 
five per cent, of phthalic acid. It is used locally as a 
styptic in bladder and uterine hemorrhages. It pro- 
duces a slight drowsiness. Styptol can be used instead 
of ergot or ergotin as a hemostatic. It is used also pre- 
ceding menstruation in menorrhagia, metrorrhagia, 
and dysmenorrhea, and in hemorrhage during the 
menopause, in pregnancy, or from uterine fibroids. 
Dose, i grain (0.0.5) three times a dav. 

"R. .1. E. SroTT. 



Styrax. — Storax, U. S. is a balsam prepared from 
the wood and inner bark of Liquiilamher nrientalis 
Miller (fam. Hamamelidacefe). This balsam is a disease 
product, resulting from wounds inflicted upon the bark 
of the medium-sized tree named above, which re- 
sembles the sweet-gum tree (L. dyraciflua L.) of the 
eastern United States. 

The styrax tree occupies a limited area in the south- 
western districts of Asia Minor, where it forms forests. 
It is collected by bruising, and after some time remov- 
ing the outer bark, then scraping off and boiling the 
inner bark with sea water. The oleoresin thus melted 
out rises to the top and is skimmed off. By pressure, 
an additional amount can be obtained from the re- 
maining bark. 

Storax is a semi-liquid, gray, sticky, opaque mass, 
depositing, on standing, a heavier dark brown stratum; 
transparent in thin layers, and having an agreeable 
odor and a balsamic taste. Insoluble in water, but 
completely soluble (with the exception of accidental 
impurities) in an equal weight of warm alcohol. If 
the alcoholic solution, which has an acid reaction, is 
cooled, filtered, and evaporated, it should leave not 
less than seventy per cent, of the original weight of 
the balsam, in the form of a brown, semi-liquid 
residue, almost completely soluble in ether and in 
carbon disulphide, but insoluble in benzin. When 
heated on a water-bath, storax becomes more fluid, 
and if it be then agitated with warm benzin, the 
supernatant liquid, on being decanted and allowed 
to cool, will be colorless, and will deposit white 
crystals of cinnamic acid and cinnamic ethers. This 
balsam consists principally of an amorphous sub- 
stance named sloresin. It also contains several 
cinnamic ethers and cinnamale of cinnamyl (styracin), 
which can be prepared in rectangular prisms, and 
cinnamic acid and sttjrol. 

In its action storax varies very little from a number 
of other balsamic substances; internally it has been 
used in bronchitis and similar conditions with but 
moderate success. As an ingredient of liniments, 
ointments, etc., it is quite useful. The compound 
tincture of benzoin contains eight i)cr cent, of storax. 
Dose of storax, from three to five drops. 

Allied Plants. — The Sweet Gum Tree, Liquid- 
amber xtyraciflua L.. resembles the above species and 
supplies a non-drying sticky balsam resembling storax 
in medicinal properties, although not in color or 
opacity. Henry H. Rcsby. 

11 



Sublanilnr 



REFERENCE HANDBOOK OF THE MEDIC.\L SCIENCES 



Sublaminc, etliylcnc diamine mereury sulphate, 
is a red, very soluble salt of mercury, which is em- 
ployed as a non-irritant antiseptic substitute for 
corrosive sublimate. It is not decomposed by soap, 
does not readily coagulate albumin, and docs not 
harden the skin; yet many experiments have shown 
it to possess marked bactericidal pro[)ertics, with a 
greater penet rating power than has mercuric bichloride. 
The ethylene-diamine mercury citrate has practically 
the same properties, but is a liquid. 

W. A. Hastedo. 
U. .1. ]■'.. Scott. 



Suffocation. — This term is applied to one form 
of asphyxia, others being drowning, strangulation, and 
hanging. In the article Aspki/xia will also be found 
a brief account of suffocation with special reference to 
forensic medicine. Generally speaking suffocation 
refers to any condition other than the three mentioned 
above, through which air is prevented from reaching 
the lungs. However, the individual forms of suffoca- 
tion differ greatly among themselves, and some of 
them belong practically under other subjects. 

One form of suffocation is closely allied to strangu- 
lation, in which the windpipe is compressed from 
without. In this form the thorax is compressed for a 
certain length of time sufficient to produce death by 
asphyxia. The condition may not rejjresent uncom- 
plicated suffocation, for a shock component is often 
present. If a heavy weight is placed on the thorax 
the latter is immobilized and held in the extreme 
expiratory position, while at the same time a reflex 
closes the glottis. The air which remains in the lungs 
is under increased pressure, so that the blood is forced 
from the great veins backward into the venous circu- 
lation. As the inferior cava is provided with valves 
ecchymoses do not occur to any extent below a certain 
level in the thorax. The superior cava and tribu- 
taries, however, have no valves and a certain amount 
and distribution of ecchymoses are seen in the head, 
neck, face, and upper part of the trunk. In sudden 
and extreme compression, however, the entire area 
over which the superior cava presides is involved, 
so that a characteristic picture obtains on the head, 
neck, throat, shoulders, arms and upper portion of the 
thorax. At first sight the parts are swollen and blue 
black and appear to be the seat of an intense cyanosis 
but inspection sliows the presence of small closely 
aggregated ecchymoses, due to the enormous increase 
in the Ijlood pressure. The forms of compression of 
the chest are numerous, depending on the nature of 
the causes. Compression may be anteroposterior or 
lateral, and compression of the abdomen by forcing 
upward and immobilizing the diaphragm produces 
the same result as direct compression of the chest. 
This type of suffocation often goes by the name of 
traumatic asphyxia. 

Most striking, because it so often occurs en masse, 
is suffocation from trampling on the chest and abdo- 
men in panics. At the coronation of Czar Nicholas II 
at Moscow 3,000 people were trampled to death, and 
this was the cau.se of many deaths at the Ring 
Theater, Vienna, when the audience sought to escape 
the flames by crowding through a single narrow exit, 
the doors of which opened inward. 

Accidents of the "avalanche" type also cause 
death by compression of the trunk when large pieces 
of masonry fall. In cases of this sort in addition to 
mechanical compression much added traumatism 
may be present. 

Buffer accidents such as commonly cause contusion 
and crushing of the thorax under certain conditions 
may also cause death by suffocation. If the com- 
pression is brief and incomplete life may be saved, the 
patient presenting a characteristic symptom-complex. 
Exophthalmos and rigid pupil (chiefly in mydriasis) 
and temporary blindness may occur while conscious- 

12 



ness is often lost. The characteristic ecchymosed 
condition in the area drained b.v the superior vena 
cava, and already described is present. The in- 
dividual ecchymo.ses range in size up to that of a 
bean. This discolored area is sharply marked off 
from the normal integument of the chest. If death 
has occurred the same phenomenon persists, and in 
extreme cases rupture of intracranial veins also occurs. 

In the forms of compression of the chest already 
described, death is purely the result of an accident. 
Homicides, however, are sometimes brought about by 
sitting or kneeling on the trunks of feeble individuals, 
drunken men, infants, and other helpless subjects. 
It is a question, however, whether death is deliberately 
brought about in this manner. The act of sitting or 
kneeling on the trunk seems to be intended primarily 
to render the individual powerless. Smothering in 
such cases by placing the hands over the face is no 
doubt resorted to. This was the method used by the 
body snatchers of the eighteenth century in Great 
Britain. In other cases fatal compression of the chest 
may occur without intention in fighting and in criminal 
assaults upon women. The same result has occurred in 
the murders of infants and young children, when the 
real object was simply to incapacitate them and prevent 
their cries. In other cases gradual suffocation may be 
brought about deliberately by this means, the hands 
also being held, apparently with the view of preventing 
evidences of a struggle. The plan no doubt succeeds 
at times, as the ecchymoses may not appear. In 
such cases suffocation is difficult to prove, in compari- 
son with other forms of asphyxia. The slightest 
scratches and bruises then assume importance. 

Simple smothering by mechanical occlusion of the 
breathing orifices is one of the commoner causes of 
death by suffocation. The circumstances vary much 
with the case. Accidents of the avalanche t.vpe occur 
in which the subject is buried under loose earth, grain, 
flour, etc. Owing to the porous condition of these 
substances some air reaches the patient, and he may 
survive for a variable time, or if apparently dead may 
be resuscitated. The conditions are different if a 
man, while intoxicated or exhausted, fall face down- 
ward upon a heap of ashes or the like. In accidents 
like the preceding, some of the loose substance usually 
enters the nose and mouth and may be swallowed 
or aspirated; or if the subject fall upon them, the 
imprint of formed objects may be visible. .'\11 such 
evidence tends to support the view of accidental death 
caused in the manner indicated although homicide is 
not necessarily excluded. Young infants die by 
thousands annually as a result of smothering chiefly 
by overlaying in bed, also by misuse of shawls and 
coverings. The vast majority of such deaths are due 
at most to criminal carelessness. But many infants, 
as well as old, sick, helpless, and drunken adults have 
been deliberately smothered by holding coverings or 
the hands over the face and even by turning quite 
helpless subjects face down on the bed. Pitch plasters 
have sometimes been used with the double aim of 
stilling outcries and smothering. Despite the prr- 
cautions of the murderer there may be present 
minimal traumatisms about the mouth or nostrils 
which indicate a struggle. Suffocation in homicidal 
cases can sometimes be recognized only by excluding 
all other causes of death. Suicide by this route is 
almost unknown. 

Suffocation of the "living burial" type sometimes 
results from very close confinement in which o.xygeiia- 
tion becomes impossible. But little exists in recent 
literature on this subject. 

One of the commoner forms of suffocation, some- 
times seen also in homicides, is simple occlusion of the 
natural passages by foreign bodies or matter of any 
kind. The aspiration of vomited matters constitutes 
a well-known clinical form, in which the cause of death 
m.ay be obscure. In the absence of any history foul 
play may be suspected. The state of affairs is much 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



the same in certain cases of choking to death. Cases 
of this type are readily cleared up by autopsy. In- 
fants may be smothered from mere clogging of the air 
passages by mucus, or there may be a latent capillary 
bronchitis. In such cases there may be a false charge 
of intentional smothering. 

Foreign bodies such as rubber nipples are occasion- 
ally aspirated by infants with fatal results, while 
infanticide by inserting a finger or a piece of cork or 
similar substance into the glottis is by no means un- 
known. In such cases the introduction of the foreign 
body is usually designed to cause death without detec- 
tion, but it is conceivable that after ordinary smother- 
ing, objects could be introduced into the larynx to 
give the impression that they had accidentally been 
swallowed. Infants have been strangled by intro- 
ducing pepper into their throats. 

The pathology of suffocation is for the most part 
comprised under asphyxia as a general condition. If 
we exclude drowning, hanging, and strangulation, 
then asphvxia and .suffocation for the most part 
coincide, clinically and on section. 

For the treatment of suffocation, see the article on 
liesnncitalioii. Edw.\rd Preble. 



Suggillation (more properly sugillation, from 
suaillnre, to beat black and blue). — In the older 
literature this term is used to designate superficial 
areas of discoloration, as black and blue spots, ecchy- 
moses. hj-peremic spots, livid marks or patches, or 
various spots occurring in the skin in different dis- 
eases. The patches of discoloration in the skin of the 
cadaver due to postmortem hj-postasis or incipient 
putrefaction were likewise termed suggillations 
(suff'llntio). More recently, through the influence of 
the German school, the term has come to be applied to 
hemorrhages into or beneath the tissues, of a larger 
size than ecchymoses; and with this usage there is also 
conveyed the idea of a suffusion of the tissues with 
blood. The term is, therefore, used interchangeably 
with bloody suffusion, and is applied to more or less 
flattened, diffuse swellings of the skin due to hemor- 
rhage into the subcutaneous tissues, or to similar 
hemorrhages occurring in other loose tissues. A 
suggillation is distinguished from a hematoma by 
the fact that in the former the tissues are infiltrated 
with blood but not torn apart so as to form a distinct 
cavity filled with blood. Suggillations are usually 
due to direct trauma, but occur in cases of both con- 
genital and acquired hemophilia. In the latter case 
they may result from the changes produced in the 
blood-vessel walls through intoxication or infection. 
Suggillations of the skin may take place in pernicious 
anemia, Icucemia, sepsis, chronic icterus, and in the 
hemorrhagic forms of the acute infections. In 
typhoid fever suggillations of the abdominal recti 
may occur as the result of extensive parenchymatous 
changes (Zenker's necrosis) in the muscle. The 
sequeljE of suggillation are similar to those of hem- 
atoma — absorption, organization, or cyst formation. 
Aldred Scott W.^rthin. 



Suicide. — The literature of suicide is so extensive 
that it would serve no useful purpose to enlarge upon 
the general aspects of a most important problem in 
medicine and social pathology. Of the earlier English 
literature, "An Essay Concerning Self-Murther where- 
in is Endeavored to Prove that It Is Unlawful Ac- 
cording to Natural Principles. With some Consid- 
erations upon What Is Pretended from the Said 
Principles," was published in London in 1700 by J. 
Adams, rector of Saint Alban, and Chaplain in Or- 
dinary to His Majesty. The arguments against sui- 
cide on moral and spiritual grounds were as conclusive 
at the time as they are to-day. Commencing with 
1716, a series of papers was published by clergymen 



and others, concluding with a most interesting tract 
on "Cato Condemned: Or, The Case and History of 
Self-murder, Argued and Displayed at Large, on the 
Principles of Reason, .lustice. Law, Religion, Fortitude, 
Love of Ourselves and Our Country, and E.xample," 
with "A Solution of This Problem. Whether a Man 
of Sen.se, Goodness and Courage, Ever Did, or Can, 
Kill Himself? Particularly Calculated to Prevent 
It in the English Nation." In 1707 there was 
published at Boston a sermon on "The Sin of Suicide 
Contrary to Nature. A Plain Discourse Occasioned 
by the Late Perpetration of That Heinous Crime: 
Published for a Warning to Survivors; .Vt the General 
Desire of the Hearers: Unto Whom It Is Dedicated." 
Theauthor of this sermon was the Rev. Simon Phillips, 
Pastor of the South Church in .\ndover. In 1790 
an elaborate work entitled "-\ Full Inquiry into the 
Subject of Suicide," was published in London, in two 
volumes, by the Rev. Charles Moore, which to this 
day constitutes one of the mo.st useful contributions 
to the subject, including historical and legal observa- 
tions of great value, and concluding with a chapter on 
"Some Precautions or Preservatives Proposed against 
Falling Under a Temptation to the Commission of 
Suicide." The literature of the nineteenth and early 
twentieth centuries presents no new aspects of this 
lamentable phase of modern life. The works of 
Morselli and Strahan may be referred to as excellent 
presentations of the general facts of suicide, with 
special reference to its statistical aspects. One of the 
most recent contributions of great value is the "Sta- 
tistics of Suicide in the Kingdom of Saxony," bj" Dr. 
O. Kurten, published in Leipzig and Berlin, 1913. 
.\11 that has been written on the subject merely 
tends to confirm earlier views and conclusions that 
suicide, in a specialized sense, is a problem of un- 
soundness of mind and falls within the borderland of 
sanity and insanity. All the efforts made to counteract 
a suicidal tendency by an appeal to rea.son, morality 
and religion have apparently had only slight effect, 
since practically throughout the civilized world the 
tendency to self-murder has been, and continues to 
be, on the increase. The most recent effort in this 
direction is carried on by the Rev. N. M. Warren, of 
tlie Parish of All-Strangers, New York City, who is 
daily informed by the coroner of all cases of suicidal 
attempts, for the purpose of such relief, assistance and 
advice as the case may call for. 

The seriousness of the suicide problem, considered 
with special reference to the United States, is empha- 
sized in the table following, which presents an estimate 
of the probable number of suicides annually in the 
United .States during the period 1900-1.5, on the basis 
of the suicide mortality rate for the registration area: 

Estimate of the SnciDE Mortality of the Continental 
Vnited ST.tTES, 1900-1913. 





Population of 


Registration area 


Estimated suicides 




continental U. S. 


rate per 100.000 


1 in the U. S. 


1900 


75,994.575 


115 


S.700 


1901 


77,592.344 


12 2 


9,500 


1902 


79,190,113 


12 7 


10.100 


1903 


80.787,882 


13 s 


11.100 


1904 


82,385.651 


14 7 


12.100 


1903 


83.983,420 


16.0 


13.400 


1906 


85,581,189 


13.9 


11.900 


1907 


87,178.958 


15 7 


13.700 


1908 


88,776.727 


17.8 


l.i.SOO 


1909 


90,374,496 


16.5 


14.900 


1910 


91,972,266 


16.0 


14.700 


1911 


93,570.036 


16.2 


15.250 


1912 


95.167,806 


16.0 


15.200 


1913 


96,765,576 


15.8 


15.300 


1914 


98,363,346 


16.6 


lfi..300 


1915 


99,961,116 


17.0' 


17.000 



13 



REFERENCE HANDBOOK OF THE MEDIC/VL SCIENCES 



It is shown by tliis table tliat the suicide rate in 
tlie United States has increased since 1900 from 11.5 
to 17.0 per 100,000 of population. Tlie actual 
increase in the rate was, therefore, 5.5 per 100,000 of 
population, equivalent to an e.xcess in the rate for 
1915 of 43.5 per cent, over the rate for 1900. The 
actual increase in the number of suicides was ap- 
proximatelj' from 8,700 in 1900 to 17,000 in 1915. 
These estimates require to be accepted with extreme 
caution, since the borderland cases of accidents and 
homicides constitute a doubtful group, which does not 
for the time being admit of exact analysis. The 
that the probable number of deaths due to suicide in 
statistical evidence, however, is absolutely conclusive 
the continental United States at the present time (1915) 
is about 17,000 and if allowance is made for doubtful 
cases otherwise diagno.>;cd, or certified to at coroners' 
inquests, it is reasonably possible that the number of 
suicides amounts annually to not less than 20,000. 

Since the suicide rate of cities is generally higher 
than that of rural communities the following table is 
included for the jnirpose of emphasizing the degree of 
suicidal frequency in fifty American cities during the 
period 1890-1914, separately considered by single 
years and by quinquennial periods for the quarter 
century: 

MORTALITV FROM SdICIDE IN FiFTY AMERICAN CiTIES, 1890-lflll 

(Rate per 100,000 of Population.) 



Year 


Population 


Suicides 


Rate 


1890 


10.799,626 


1,345 


12.5 


1891 


11,270,519 


1,577 


14.0 


1892 


11,740,950 


1,468 


12.5 


1893 


12,047,729 


1,913 


15.9 


1894 


12.362.080 


1,947 


15.8 


1895 


12,778,209 


2.002 


15.7 


1896 


13.216.674 


2,162 


16.4 


1897 


13.538,278 


2,410 


17.8 


1898 


13,942,147 


2,434 


17.5 


1899 


14,269,472 


2,367 


16.6 


1900 


14,703,398 


2.494 


17.0 


1901 


15,120,091 


2,573 


17.0 


1902 


15,549.790 


2,875 


18.5 


1903 


15,973.505 


3,181 


19.9 


1904 


16,397,223 


3,392 


20.7 


1905 


16,847.630 


3,276 


19.4 


1906 


17..'!.-)0.275 


3.179 


18.3 


1907 


17.s.'iL>,926 


3.498 


19.6 


1908 


ls.:i.ir,„-)Sl 


4.086 


22.3 


1909 


18,S5S,238 


3.963 


21.0 


1910 


19,360,890 


3,895 


20.1 


1911 


19,863.542 


3,926 


19.8 


1912 


20,365,056 


3,878 


19.0 


1913 


20,867.602 


3.918 


18.8 


1914 


21,370,509 


4,420 


20.7 


1890-94 


58.210,904 


8,250 


14.2 


1895-99 


67,744,780 


11,375 


16.8 


1900-04 


77,750,007 


14,515 


18.7 


1905-09 


89.264,650 


18,002 


20.2 


1910-14 


101,827,599 


20,037 


19.7 



It is shown by this table that there was a persistent 
increase in the suicide rate of American cities during 
the first twenty years of the period under ob.servation, 
while the rate during the last five years has attained 
to apparently a stationary condition. The rate 
now, however, is relatively so high tliat a much further 
increase is not to be anticipated. 

Considered by quinquennial periods, it appears 
that the suicide rate of American cities during the 
last twenty years has increased from an average of 
16.8 during the five years, 189.5-1S99, to 19.7 during 
the five years, 1910-H)14. The statistical evidence is, 
therefore, tiuite conclusive that the suicidal tendency 
is distinctly on the increase in American cities, al- 
though subject to fluctuation, attributable to more or 
less profound social and economic changes. 

14 



The degree of suicidal frequency varies materially 
for the different geographical divisions of the country, 
as shown bj' the summary statistics, presented in an 
abbreviated form in the table below : 



LTiox OF .Suicides, U. S. Registr.\ 
States, 1909-1913. 
(Rate per 100.000 of Population.) 



New England and Middle Atlantic 

Southern 

Southern, white population 

Southern, colored population. .... 

North Central 

Rocky Mountain 

Pacific Coast 



Average for 25 state 



19,590 

1,674 

1,567 

107 

12,318 
1,509 
5,026 



40,117 



This table is subject to the serious limitation of 
inadequate returns for the Southern States of the 
United States, but in the main the facts disclosed 
conform to the results of other statistical investiga- 
tions, chiefly, however, with reference to the urban 
population. The table shows that the degree of 
suicidal frequency is highest on the Pacific Coast, 
where the mortality is 27.1 per 100,000 of popula- 
tion, and lowest in the Southern States, where the 
rate is 9.8. If, however, allowance is made for the 
element of color, it appears that the suicide rate for 
the white population of the South is 11.2 per 100,000, 
against a rate of only 3.3. for the colored. 

All of the statistical studies of suicide prove that 
the male sex is decidedly more inclined to self- 
murder than the female sex. In the U. S. regis- 
tration area, during the period 1904-13, the male 
suicide rate was 24.0 per 100,000, against a rate of 
7.5 for females. The table following exhibits the 
details of the suicide mortality by sex for each of the 
years 1904-13, and for the two quinquennial periods, 
including the population estimates for intercensal 
years : 



(Rate per 100,000 of Population.) 



Year 


Midyear 


No. of 


Rate 


Midyear 


No. of 


Rate 


population 


suicides 


population 


suicides 


1904 


16,856.270 


3,775 


22.4 


16,492.867 


1,137 


6.9 


1905 


17.274,352 


4,121 


23.9 


16,820,253 


1,317 


7,8 


1906 


21,322,133 


4,521 


21.2 


20,661,286 


1,332 


6 4 


1907 


21.899,144 


5,185 


23.7 


21,117,846 


1,500 


7 4 


1908 


23,876.529 


6,429 


26.9 


22.913.384 


1,903 


8 3 


1909 


26,020.431 


6.494 


25.0 


24,850.087 


1,908 


7 7 


1910 


27,606,526 


6,610 


23.9 


26,237,370 


1,980 


7.5 


1911 


30,463,411 


7,389 


24.3 


28.812,566 


2,233 


7.8 


1912 


31.128.193 


7,426 


23.9 


29.298.940 


2,230 


7.6 


1913 


32,607,069 


7,709 


23.6 


30,691,649 


2,279 


7.4 


1904-08 


101,228.428 


24,031 


23.7 


98.005.636 


7,249 


7.4 


1909-13 


147,825,630 


35,628 


24.1 


139,890,612 


10,630 


7.6 



Even more important than the sex factor is the 
incidence of age. Suicide is naturally very rare 
during early life, but evidence is not wanting that 
suicide among children is on the increase in this as 
well as in many other civilized countries. The table 
following shows the rate of suicidal frequency, by 
divisional periods of life, with distinction of sex, for- 
the U. S. registration area, 1904-13: 



REFERENCE HANDBOOK OF THE MED1C.\L SCIENCES 



Suicide 



.ITT FROM Suicide, bt Age and Sex, C. S. Registration 
Area, 1904-13. 
(Rate per 100,000 of Population.^ 



Males 


Females 


Ages at 
death 


Estimated 
aggregate 
population 


No. of 
suicides 


Rate 


Estimated 
aggregate 
population 


No. of 
suicides 


Rate 


Under 
5 yra. 
5-9 

10-14 

15-24 

25-34 

35-44 

45-54 

.io-64 

05-74 

75-84 

85 and 
over 


25,614,623 
23,388,259 
22,189,186 
47,163,061 
44,409,145 
35,466,490 
24,908,648 
14.715.018 
8,010.576 
2,760,125 

428,927 






25,048,079 
23,025.413 
21,966,362 
47,078,302 
40,703,104 
32,072,683 
22,399,785 
13,879,653 
8.129,638 
3,039,153 

554,076 






5 
132 
6,041 
11,605 
12,828 
12,749 
9,121 
4,880 
1,737 

239 
322 


0.0 
0.6 
12.8 
26.1 
36.2 
51.2 
62.0 
60.9 
62.9 

55.7 


2 

100 

4,350 

4,476 

3,432 

2,684 

1,634 

837 

291 

42 
31 


0.0 
0.5 

9.2 
11.0 
10.7 
12.0 
11.8 
10.3 

9.6 

7.6 




• 






Total: 


249,054,058 


59,659 


24.0 ] 237,896,248 


17,879 


7.5 



There is obviously a very rapid rise in the rate of 
suicidal frequency during youth and early adolescence, 
a fairly stationary rate being reached after age si.xty- 
five, when however, the returns are hardly sufficient for 
a safe generalization. It is rather striking to find 
that the maximum rate of frequency for males is 
reached at ages seventy-five to eighty-four, and for 
females at ages forty-five to fifty-four. There are 
reasons for believing that a still more extensive exper- 
ience would confirm this conclusion to the extent that 
the slight incongruities at the further advanced ages 
would be eliminated. At no period of adult life is the 
female suicide rate as high as the male rate. From a 
medical and medico-legal point of view the preceding 
table is of considerable practical importance. It is true 
that the suicidal impul.se is not measured with absolute 
precision by the suicidal mortality statistics, since 
It is conceivable that attempts may be more common, 
but less successful, at earlier ages, partly on account 
of the want of knowledge and partly because of 
lack of the required courage. The influence of this 
uncertainty, however, is not likely to be sufficient to 
materially impair the conclusion that among men 
the relative frequency of suicide, in proportion to the 
population living at corresponding ages, is greatest 
at ages seventy-five to eighty-four, followed by the age 
period fifty-five to sixty-four; and among women, at 
ages forty-five to fifty-four, followed by the age period 
fifty-five to sixty-four. The largest actual number of 
suicides, however, during the period under observation, 
occurred among men at ages thirty-five to fortj'-four, 
and among women at ages twenty-five to thirty-four. 
Suicide would, therefore, seem to occur somewhat 
earlier in life among women than among men. 

Suicide is rare among savage and relatively infre- 
quent among barbarous races. The tendency to self- 
murder increases with the progress of civilization and 
is proportionate to the complexity of modern social 
and economic life. In thirty large southern cities of 
the United States the suicide rate during 1900-12 
was only 5.9 per 100,000 for the colored, against 22.6 
for the white population. In Jamaica, where the 
population is almost exclusively colored, the suicide 
rate during 1910-14 was only 2.0 per 100,000. In 
contrast, however, the suicide rate of the colored 
population of Cuba during 1910-13 was 15.0, against 
18.0 for the white population. The colored popula- 
tion of Cuba, however, is much more intermixed with 
the white element than is the colored population 
of Jamaica. In Hawaii the average suicide rate for 
1911-15 was 23.1 per 100,000. There were no 
suicides among the Spaniards during this period, and 



the rate was lowest among the Porto-Ricans (4.0) and 
the Portuguese (4.3). Among the part-Hawaiians the 
rate was 7.2, among the pure Hawaiians 10.1. Among 
the other racial elements the rates were as follows: 
Fillipinos 12.1; Japanese 26.5; Chinese 35.7; other 
Caucasians than Spaniards and Portuguese 36.3; and 
all others 61.8. These rates cannot be considered en- 
tirely conclusive, but they are suggestive of a rela- 
tively low suicide rate among the primitive jjopulation 
and a relative high rate among the Chinese and 
Japanese. This conclusion is sustained by the suicide 
statistics of the Pacific Coast. 

Suicide among children is more common than is 
generally assumed to be the case. There are reasons 
for believing that the tendency to errors in diagnosis, 
or even the falsification of death certificates, is more 
pronounced in such cases than at older ages. Suicide 
among the very j'oung seems so unnatural an act that 
there must necessarily be a strong reluctance on the 
part of physicians and coroners to interpret the avail- 
able evidence against the parents and the child con- 
cerned. Since there are reasons for believing that 
child suicides are close relation to erroneous edu- 
cational methods, it is of the utmost importance 
that more serious consideration be given to this 
most lamentable aspect of the suicide problem. 
Deaths from self-murder are not infrequent in 
extreme old age, for, as shown by the returns for 
the U. S. registration area for the period 1904-13 
there were 3,896 suicides of males at ages seventy and 
over, and 654 suicides of females. Proportionatelj- to 
the population of corresponding ages, however, there 
is a distinct diminution in the suicidal tendency after 
age eighty-five among men, and after age seventy-five 
among women. Thus far, however, no thorough study 
has been made of the correlation of suicide to senility, 
but the available evidence would seem to justify the 
conclusion that self-murder in extreme old age is 
more common at the present time than in the past, 
just as, conversely, this appears also true of the suicidal 
impulse among young children. 

Almost without exception suicides are more 
common in cities than in rural districts. In the 
United States registration states, during the period 
1904-13, the urban suicide mortality rate was 17.7 
per 100.000 of population, against a rural rate of 
12.2. The urban rate was, therefore, 45.1 per cent, 
in excess of the rural. 

MORTAUTT FROM SuiCIDE, URBAN AND RrRAL, U. S. RegistraTIO.N 

States, 1904-13. 
(Rate per 100.000 of Population). 



Urban. 



Rural. 



Year. 




Population. 


No. of 
suicides. 


« 


Population. 


No. of 
suicides. 


1 


1904 


10 


12.029,302 


1,668 


13.9 


9,307,413 


943 


10.1 


1905 


10 


12,372,228 


1,853 


15.0 


9,3fr*.680 


1.087 


11.6 


1906 


15 


18,195,041 


2,702 


14.9 


15,640,988 


1,621 


10.4 


1907 


15 


18,737,525 


3,133 


16.7 


15,871,371 


1,894 


11.9 


1908 


17 


20,417,270 


3,992 


19.6 


18,288,591 


2.514 


13.7 


1909 


IS 


23,066,405 


4,382 


19.0 


21,215.280 


2,679 


12.6 


1910 


21 


25,187,805 


4,513 


17.9 


22.619.901 


2,796 


12.4 


1911 


23 


27,485,457 


5,256 


19.1 


20,899,777 


3,379 


12.6 


1912 


23 


28.129,824 


5,116 


18.2 


27,122,299 


3,459 


12.8 


1913 


24 


29,244,100 


5,432 


18.6 


29,068,435 


3,529 


12.1 


1904-13 




214,865,017 


38,047 


17.7 


195,398,795 


23,901 


12.2 



The exact correlation of suicide to season has also 
not as yet been determined with the required degree 
of scientific accuracy and completeness. The ob- 
servations of Dexter on "Weather Influences" may 
be referred to as exceptionally useful in the further- 
ance of this line of specialized research. Much 

15 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



more, however, is required tluui has heretofore been 
possible on the basis of crude statistics by months 
or weeks, or even davs, since obviously weather 
influences react upon niuch shorter periods of time. 
An analysis of suicide bv days of the week, and 
hours of" the day, bv Prof. William B. Bailey, in 
the Yale Review, as quoted by Dexter, shows that of 
9,5.35 cases, 3,087 occurred before noon, and 5,848 
during the remainder of the day. Of the cases of 
murder followed by suicide, roushly, seventy per cent. 
were found to have occurred during the six hours 
from ti.OO P.M. to midnight. Dexter also quotes from 
the treatise bv Strahan, that "The yearly variation in 
self-destruction dilfers from these weekly and hourly 
variations in this; that instead of the exciting cause 
coming to the individual from the outside world, it 
comes to him from within. There is an annual 
rhythmic rise and fall which affects all animate 
nature. With the approach of spring and the in- 
crease of temperature, there is a general wakening 
from the period of comparative rest in which the 
preceding cold season has been passed. With this 
awakening, every function is quickened and the 
procreative, which is the highest of all functions, is 
excited to most vigorous action. During this period 
of spring and early summer the organism is working 
at its highest tension, and every function of mind and 
body is more active than at any other period of the 
year. It is not surprising, then, that at this portion 
of the yearly cycle we should meet with the most 
breakdowns of the machine." The influence of 
weather conditions has been investigated with much 
greater thoroughness and in more exact conformity 
to scientific requirements, by Prof. Ellsworth Hunt- 
ington in his treatise on "Civilization and Crime." 
Thus far, however, no investigation of this kind can 
be considered entirely conclusive. The table follow- 
ing is intended merely as an illustration of the seasonal 
fluctuation in suicide in the combined area of twenty- 
one registration states, for the period 1910-13: 

Mortality from Sl-icide, by Season, U. S. Registration 

States, 1910-13. 

(Monthly Rate per 100,000 of Population.) 



Aggregate 
population.* 



January. . . . 
February. . . 

March 

April 

May 

June 

July 

August 

September. 

October 

November. 
December. . 



198,913,288 
181,542,776 
199,558,042 
193,427,607 
200,202,796 
194,061.408 
200.847,550 
201,169,932 
194,987,4.')0 
201,814,680 
195,611,389 
202,459,440 



Winter 580,014.100 

Spring 587,691,811 

Summer I 597,004.932 

Fall 699,885,515 



2,269 
2,178 
2.673 
2,735 
2,876 
2,857 
2,668 
2,557 
2,485 
2,446 
2,434 
2.384 

7,120 
8,468 
7,710 
7,264 



Monthly average 2,364.596.364 30,562 



1.14 
1.20 
1.34 
1.41 
1.44 
1.47 
1.33 
1.27 
1.27 
1.21 
1.24 
1.18 

1.23 



This table has been corrected for the varying 
lengths of the months, but in brief the rate was high- 
est during the spring months, or 1.44 per 100,000 
of monthly population, followed by a rate of 1.29 
for the summer months, 1.23 for the winter months, 
and 1.21 for the fall months. The highest monthly 
incidence occurred in June, when the rate attained to 
1.47 per 100,000 of population. 

The method of suicide varies according to sex, and 



quite materially for the dilTerent civilized countries of 
the world. Tlie table following exhibits the methods 
employed in the suicides occurring in the United 
States" registration area, 1910-13, arranged in con- 
formity to the international classification. 



Mortality from Suicide, bt Method and t 
(U. S. Registration Area, 1910- 


According 
13.) 


TO Sf:? 




Males. 


Fern 


ales. 


Method. 


No. of 
suicides. 


Per cent. 


No. of 
suicides. 


Per eent. 




10,201 
7,040 
4,499 
2,981 

2,185 

1,363 

387 

298 

180 


35.0 
24.2 
15.5 
10.2 

7.5 

4.7 

l.:i • 
1.0 

0.0 


945 
3,955 

956 
1,434 

299 
734 
222 
51 

126 


10, S 


Poison 


45 4 


Hanging or strangulation. . 


11 
16.5 


Cutting or piercing instru- 


3 4 




8.4 


Jumping from high places. 


2.5 
0.6 


Other methods, or not 


1 ,4 








29,134 


100.0 


8,722 


100.0 







* Standardized for variation in length of months. 



It is shown by this table that the predominating 
method of suicide among men was by firearms, and 
among women it was by poison. It is regrettable that 
details should not be available to disclose the nature 
of the poison employed, since restrictive measures 
aiming at more effective control in the sale of poison 
would necessarily have to be based upon the kind of 
poison made use of. Much better and more useful 
returns of this kind are published annually by the 
Registrar-General for England and \yalcs. The large 
proportion of suicides by firearms is obviously sug- 
gestive of more effective legislative restrictions in the 
sale of dangerous weapons. 

The alleged motives for suicide are the least 
satisfactory statistical returns even under the best 
possible conditions. Probably the most tru.st- 
worthy statistics are those of France, which nic 
presented in the table below, for the period 1906-10: 



Suicide According to Motives, in France 


(1906-191(1) 




Males. 


Females, 


Motive. 


No. of 

suicides. 


Per 


No. of 
suicides. 


Per 
cent. 


Poverty or fear of poverty. .... 

Economical embarrassment, 

loss of position, iosa by law- 


2,905 

2,337 
3,118 

1,150 

655 

5,274 

781 
8,191 

172 
2,367 
5,059 
4,909 


7.9 

6.3 

8.4 

3.1 

1.8 
14.3 

2.1 
22.2 
0.3 
6.4 
13.7 
13.3 


766 

278 
1,257 

991 
155 
631 

106 
2,415 


'1 
2.5 




11.3 


Disappointment in lov<.', jeal- 


R '.1 


Debauchery, misconduct 


1 4 

.S 7 


Desire to evade judicial or dis- 
ciplinary punishment 


1 II 
21 ,s 


Disgust with military service. . . 




804 
2,443 
1,235 


7.3 




22.0 




11.2 






Total.. 


36,918 


100.0 


11,081 


100.0 







According to this analysis the predominating motive 
for suicide among men was physical suffering; 



16 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



and among women mental affections, and physical 
suffering to practically the same degree. From a 
medical point of view thi.s evidence is extremely sug- 
gestive. For the United States the evidence is 
quite conclusive that unwillingness to endure physical 
suffering is, to an increasing e.xtent, an underlying 
cause of, or reason for, self-murder. A large number 
of individual ca.ses are available to prove that at 
least the alleged motive was an unwillingness to 
undergo a surgical operation or to continue the 
unavoidable endurance of physical suffering. In the 
case of cancer particularly this has been so to a 
sufficient e.xtent to require consideration in con- 
nection with the question as to the actual or apparent 
increase in cancer frequency. The preceding table, 
which has been derived from the judicial statistics 
of France, may be accepted as an approximately 
trustworthy indication of the probable underlying 
motives for suicide, and there are no reasons for 
believing that the returns, if available for this country, 
would differ very materially from those of the French 
Republic. 

International statistics of suicide are of doubtful 
intrinsic conclusiveness. Methods of coroners' in- 
quests, death certification, etc., vary sufficiently to 
invalidate the scientific conclusiveness of the returns 
for certain countries with fundamentally different 
codes of judicial procedure as well as essentially dif- 
ferent manners and customs from those common to 
the L'nited States and other countries with populations 
largely of Anglo-Saxon origin. The crude suicide 
rates, unless standardized for variations in age and 
sex distributions, are also likely to be seriously im- 
paired for comparative purposes on this ground in 
addition to the underlying difficulty of medical diag- 
nosis, coroners' inquests, and death certification. 
Since, however, international statistics are quite 
generally made use of in connection with medical 
and other considerations of the suicide problem, it 
has seemed best to include the following table, which 
has been derived from official sources: 

MORT-\UTT FROM SciCIDE THROUGHOUT THE WoKLD (I902--1911) 

(Rate per 100,000 of Population.) 





I 


Changes in the rate 
during the last decade. 








Actual. 


Percent. 


.Switzerland 

France 

Germany 

Hungary 


22.7 

21.4 
18.4 
18.1 
17.8 
15.5 

15.5 
12.9 
12.1 

10.2 
8.8 
7.3 
6.6 
5.8 
5.1 
3.4 
2.5 


22.6 

21.1 
18.0 
17.6 
17.8 
14.4 

14.2 
12.5 
12.6 

10.2 
8.9 
6.5 
6.6 
6.1 
5.2 
3.4 


22.9 
22.0 
21.7 
18.8 
18.7 
17.8 
16.6 

16.4 
13.2 
11.7 

10.2 
8.7 
8.1 
6.7 
5.5 
5.1 
3.4 


+0.3 

+6'6 
+0.8 
+ 1.1 

+ 2.2 

+ 2.2 
+0.7 
-0.9 

-0^2 
+ 1.6 


1.3 

2^8 
4.4 
6.3 






Sweden 


15.3 


U. S. Registra- 
tion Area 

Belgium 

Australia 

England and 
Wales 

Uruguay 

Italv. . . 


15.5 
5.6 

7.1 

24 B 


Holland 


+0.1 1.5 


Scotland 


-0.6 9.8 
-0.1 1.9 








+0.2 8.3 




' 




Total 


14.6 


14.1 


15.0 


+0.9 


0.4 



During the ten-year period under consideration the 
suicide rate increa.sed from an average of 14.1 per 
100,000 of population during 1902-00 to 15.0 during 
1907-11. The rate was higliest for Switzerland, or 
22.9 per 100,000 of population during 1907-11, and 
lowest for Spain, wlicre the rate during the same 



period was only 2.6. There are no convincing reasons 
for questioning the approximate accuracy of this 
comparison, and the data, in the main, may be relied 
upon as conclusive. The table has been limited to 
countries for which the returns are of a sufficient de- 
gree of intrinsic trustworthiness to justify their being 
utilized for comparative purposes. As an additional 
illustration, however, the following table of the suicide 
rates of large cities throughout the world is included, 
since obviously the statistics of cities are, in the main, 
more trustworthy than those available for large, 
political areas: 



(Rate per 100.000 of Population.) 



San Francisco 

Leipzig 

Hamburg 

BerUn 

Dresden 

Stockholm 

St Louis 

Frankfort a/M 

Vienna 

Denver 

Brussels 

Zurich 

Buenos Aires 

Copenhagen 

Paris 

Havana 

.Milan 

Chicago 

Rome 

Munich 

New Orleans 

Cleveland 

New York City 

Basel 

Baltimore 

Boston 

Philadelphia 

Rio de Janeiro 

Tokio 

Antwerp 

Sydney 

Moscow 

Madrid 

London 

Naples 

Melbourne and suburb: 

Birmingham 

Manchester 

Edinburgh 

Calcutta 

.\msterdam 

Liverpool 

Christiania 

Toronto 

Montevideo 

Belfast 

Montreal 

Dublin 

Mexico City 

Manila 



Period. Rate. 



United States 1904-13 

Germany 1909-13 

Germany 1904-13 

Germany 1904-13 

Germany 1904-13 

Sweden 1903-12 

United States 1904-13 

Germany 1904-13 

Austria 1903-12 

United States 1904-13 

Belgium 1903-12 

Switzerland 1903-12 

Argentine Republic. . 1904-13 

Denmark 1903-12 

France > 1902-11 

Cuba 1903-12 

Italy 1903-12 

United States 1904-13 

Italy 1904-12 

Germany j 1903-12 

United States ' 190-1-13 

1904-13 
1904-13 
1903-12 
1904-13 
1904-13 
1904-13 
1904-13 
1904-12 
1903-12 
1904-13 
1903-12 
1901-10 
1904-13 
1903-12 
1904-13 
1904-13 



United States. . 
United States.. 
Switzerland. . . . 
United States. . 
United States. . 
United States. . 

Brazil 

Japan 

Belgium 

Australia 

Russia 

Spain 

England 

Italy 

Australia 

England 

England '■ 1904-13 

Scotland : 1905-13 

India ; 1904-13 



Holland 

England 

Norway 

Canada 

Uruguay 

Ireland 

Canada 

Ireland 

Mexico 

Philippine Islands. 



1904-13 
1904-13 
1903-12 
1904-13 
190.3-12 
1904-13 
1904-13 
1904-13 
190.5-13 
1904-13 



48.0 
37.9 
36.0 
34.3 
34.0 
33.0 
32.8 
32.7 
30.5 
29.8 
28.5 
28.2 
27.2 
27.1 
25.5 
23.0 
22.7 
21.7 
21.6 
21.5 
18.7 
18.6 
17.8 
17.5 
16.7 
16.2 
16.2 
16.0 
15. S 
15.4 
13.2 
12.9 
12.3 
11.4 
10.8 
10.8 
10.4 
9.7 
9.4 
9.3 
7.6 
7.2 
7.1 
5.5 
5.0 
4.6 
4.3 
3.3 



Vol. VIII.— 2 



This table, in each and every case, gives an average 
rate for a period of sufficient length, whch in the large 
majority of cases covers the years 1904-13. For a 
few of the cities, however, the period has been made 
to terminate with an earlier year on account of the 
nonavailability of more recent data. Throughout, 
however, the statistics may be considered strictly 
comparable, and the table brings out the surprising 
fact that the highest suicide rate for any large city 
of the world is for San Francisco, while the lowest 
rate is for Manila, Philippine Islands. 

In the strict scientific sense of the term it is, to say 

17 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



the least, inisleadiiig to speak of the heredity of suicide, 
althougli the inheritance of a suicidal tendency in 
persons with a family record of self-murder has been 
conclusively established by numerous trustworthy 
cases. The statement of Strahan that a careful study 
of the family histories of suicide demonstrates that 
frequently suicide "runs in families" as suicide, is quite 
in conformity to the facts of observed experience. 
This conclusion, however, does not justify the common 
error of assuming that suicide is directly inherited, or 
transmitted from parent to child, in the same son.sc a-s 
specific racial or individual traits or characteristics arc 
transmitted, from one generation to another. Suicide 
is not an entity in tlie sen.se of a specific disease, hke 
leprosy or tuberculosis, but it is a phenomenon of 
wrongful conduct arising out of a more or less dis- 
ordered state of mind. Whether it is true, as asserted 
by Strahan, that "we know as a fact that there is no 
abnormal constitutional .state more commonly trans- 
mitted from parent to child than this tendency to self 
destruction," the evidence made available through the 
analvsis of family records by Davenport is conclusively 
to this effect, in a discus.sion of the feebly inhibited, 
with special reference to the specificity of the suicidal 
impulse, Davenport concludes that "suicide is not in- 
herited, but only a tendency to an impulse that leads 
to suicide" and he points out that "the impulse is in- 
deed quite distinct from the act." This conclusion, 
based upon perhaps the most careful stvidy made of 
the subject, is of exceptional practical importance, for 
it justifies the further conclusion that most persons in- 
hibit tlie impulse, but it is the feebly inhibited who 
give way to it." Davenport refers to forty families in 
eighteen cases of which one of the parents of a suicide 
also committed suicide. The logical result of such in- 
vestigations is to emphasize the urgency of a better 
practical understanding of the underlying physiological 
and p.sychological considerations which condition, if 
they do not determine and even pre-determine, the 
correlation of suicide to temperament. 

An exceedingly imjjortant but much neglected as- 
pect of the suicide prnhlem is the question of a directly 
or indirectly inherited tendency to self-murder. Tlie 
number of family records subjected to critical exami- 
nation is too limited in extent to justify far-reaching 
conclusions at t he present time. .\s said in my discus- 
sion of the suicide record for 1915 {Spectator, Nov. 30, 
1916) : Wliether a tendency to commit suicide is 
directly inherited or not, it can no longer be ciues- 
tioned, as shown by the investigations made by 
Charles B. Davenport and others, that a liability to 
self-murder runs in families w'hich are scientifically 
defined as "feebly inhibited." As observed by Dr. 
Davenport, a suicidal tendency can, not infreciuently, 
"be traced back through three generations, and this 
is about as far as the memory of man extends." He 
advances the important conclusion that "suicide fol- 
lowing arteriosclerotic depression probably tends to 
run in families, as the arteriosclerotic basis is still 
found to do," and while he holds that suicide, in the 
limited sense of the term, is not inherited but only a 
tendency to an impulsion that leads to suicide, he 
concludes that while many per.sons may experience 
the suicidal impulse, "it is the feebly inhibited who 
give way to it." The investigations by Davenport 
are of much greater practical significance to life insur- 
ance companies than has heretofore been recognized, 
however intrinsically difficult the scientific considera- 
tions may appear to be. In other words, whether it 
would be feasible on the jjart of life insurance com- 
panies to take into consideration the facts of tempera- 
ment, and the inheritance of ancestral temperamental 
traits, in addition to such physical and medical con- 
siderations as generally govern the selection of lives 
for insurance, is secondary to the question, for the 
time being, as to whether it would not be desirable 
to attach more serious significance to suicide in the 
family history than is generally the case. 

18 



Among other involved aspects of the suicide prob- 
lem, admirably summarized by Dr. George M. Gould, 
in a paper on "The Mysteries and Sources of .Suicide, ' 
Medical Record. Sept. 8, 1906, reference may be maile 
to secret drug-taking, venereal diseases, scoliosis and 
diseases consequent upon eye-strain, other than spinal 
curvature. Further research work in these directions 
would unquestionably reveal much valuable informa- 
tion, u.seful to the effort at suicide prevention, which 
is by no means as hopeless as generally assumed. 
The effort at prevention must, however, rest upon 
much more qualified technical knowledge than is com- 
mon to the average medical practitioner at the present 
time. As well said by Dr. Tom R. Williams, after 
pointing out that the suicide's common sense, religion, 
and ordinary medical advice have generally failed, 
"special psychopathological knowledge is required," 
for "it is by means of this that the patient acquires 
an understanding of the perverted adaptability and 
learns means of adjustment." Obviously the neces- 
sary reeducation of the patient reciuires a teaching 
capacity of a high order. In a large number of cases, 
however, there are reasons for believing that the fun- 
damental causative factor is eye-strain and that the 
remedial measures lie rather within the province of 
the oculist or expert in errors of refraction than within 
the field of the general practitioner. 

The foregoing st.atistical and other observations 
are intended to emphasize the more important prac- 
tical aspects of the suicide problem, which, however, 
is entirely too complex to permit of complete presen- 
tation within the present limitations. For additional 
data, with special reference to life insurance, the 
annual suicide records published in The Spectator, a 
New York insurance periodical, should be consulted. 
Frederick L. Hoffman. 



Sulphides. — Sulphides of four metallic bases 
have been employed as medicines, namely, sulphides 
of mercury, antimony, potassium, and calcium. Of 
these, the sulphides of antimony and potassium are 
no longer used; and the sulphide of mercury will be 
found discussed under the title HyDRARGYRrM. The 
sulphide of calcium is official in the United States 
Pharmacopoeia as Calx Sulphurata, and is considered 
below. 

The common characteristics are, physicalh', an 
alkaline reaction, a disagreeable smell, and an alkaline 
and offensive sulphureted taste; physiologically, 
quite intense, irritant properties, and a special obnoxi- 
ousness to animal and vegetable skin parasites; and, 
therapeutically, a local healing influence over many 
skin diseases in their chronic stage, and, given inter- 
nally, an uncertain tendency to abate chronic glandu- 
lar, or cutaneous, or arthritic disea.se, and to control or 
repress suppuration. In full dose too long continued, 
the compounds tend to impair general nutrition, 
leading to emaciation and muscular weakness. 

Calx Sulphurata: SulphuratedLime. — The prepara- 
tion thus named in the United States Pharmacopoiu 
is what is commonly, but incorrectly, called sulplndr 
of calcium. It is a mixture in varying proportions of 
calcium sulphide, calcium sulphate, and carbon, but 
should contain at least sixty per cent, of calcium 
sulphide — the salt which gives the substance its 
medicinal activity. Sulphurated lime is made, liy 
the process directed in the United States Pliar- 
macopceia, by heating to a bright red heat in a 
closed crucible a mixture of dried calcium sulphatr, 
charcoal, and starch. The product, after coolill^, 
is pulverized, and at once put up in small gla.<>- 
stoppered vials. It appears as a grayish-white nr 
yellowish-white powder, which slowly decomposes on 
exposure to the air. It has a faint odor of hydrogen 
sulphide, and an offensive and alkaline taste. It is 
alkaline in reaction, is very slightly soluble in cold 



REFERENCE HANDBOOK OF THE MEDIC,\L SCIENCES 



Salpbonmetbanum 



water, more readily in boiling water, and insoluble in 

alcohol. 

Sulphurated lime has the general properties of the 
alkaline sulphides, as already detailed. It is power- 
fully irritant, even medicinal doses being apt to upset 
the .stomach. And it is a disagreeable medicine for 
internal taking, also, because of its giving rise to 
eructations of sulphureted gases. The preparation has 
been used, locally, principally as a depilatory. For 
this purpose it is applied in powder, and, after fifteen 
minutes, the part is wiped with a wet sponge. Medi- 
cine and hairs then come away together. Internally, 
sulphurated lime has acquired a certain reputation 
as tending to control suppurations, the discharge 
lessening in quantity and offensive pus acquiring 
a better character under the medication. Given 
between times in recurring suppurations, as in recur- 
ring crops of boils, it is also held to abate the frequency 
and severity of the attacks. The dose of sulphurated 
lime ranges from gr. ,'0 to gr. -,',; (0.003-0.006) several 
times a day, or even hourly, given most conveniently 
in trituration with sugar of milk. 

Edward CrRTis. 
R. J. E. Scott. 

Sulphites. — I. General Medicinal Properties 
OF Sulphites .\xd Thiosulphates. — A number of 
sulphites and thiosulphates (hyposulphites) are used 
in medicine because of a virtue which they are con- 
sidered to derive, in common, from their acid radicals, 
and accordingly such salts form a distinct group of 
medicines, which it is convenient to discuss under a 
single heading. The class characteristics are as 
follows: The salts are soluble in water, have a com- 
bined saline and sulphurous flavor, and are, in physio- 
logical operation, locally bland and constitutionally 
innocuous. From a medicinal point of view, their 
most important reaction is that in the presence of 
stronger acids they are decomposed, with the evolu- 
tion of sulphurous acid. Given medicinally, they are 
thought to undergo this change in the stomach through 
the agency of the free acid of the gastric juice. 
The decomposition is said to be slower with "hy- 
posulphites" than with sulphites. As a secondary 
result of the chemical change, sulphates are formed, 
such being the combination in which the base reap- 
pears in tlie urine when a sulphite or "hyposulphite" 
is swallowed in ordinary dosage. Medicinally. 
these salts are employed with the single view of 
obtaining by their means the germicide and antiseptic 
action of sulphurous acid. But in this connection it 
must carefully be borne in mind that sulphites and 
"hyposulphites," while maintaining their chemical 
composition as such, have been proved experimentally 
to be practically devoid of either germicide or anti- 
septic power. They can, therefore, even theoreti- 
cally, be of avail in this line only under circumstances 
determining their decomposition and the evolution 
thereby of sulphurous acid. Such reaction may take 
place in the stomach, but is seemingly impossible in 
the blood, and with the inference naturally following 
from these premises clinical experience is in accord. 
For these salts have been vaunted in the treatment 
of pyrosis and sarcina", and their employment has 
proved fairly efficacious; but they have been even 
more strenuously advocated for the treatment of 
constitutional diseases assumed to be caused by 
infection of living organisms (PoUi), and have, in the 
hands of the majority of the profession at least, 
signally failed. The salts have also been used, with 
variously reported success, as lotions for the cure of 
parasitic skin disease, or for the abatement of the 
pain of chilblains, sprains, etc. — applications in 
which it is certainly doubtful if they e.xert any specific 
influence. 

II. The Sulphite.s and Thiosulphates Used ix 
Medicin-e. — The salts of this category are the normal 



and acid sulphite, respectively, of sodium, and the 
normal thiosulphate of sodium (also called hyposul- 
phite) . 

Normal Sodium Suplhite, Na^SOj + 7H2O. — The 
salt is official in the United States Pharmacopoeia as 
Sodii Sulphis, Sodium Sulphite. It occurs in colorless, 
transparent, monoclinic prisms, which effloresce in 
dry air. It is odorless, with a cooling, salty, and 
sulphurous taste. It is soluble in two parts of water at 
25° C. (77° F.), and in 1.4 parts of boiling water. 
It is sparingly soluble in alcohol. The salt should be 
kept in well-stoppered bottles in a cool place. 

Sodium sulphite may be used locally in twelve-per- 
cent, aqueous solution, and may be given internally 
in do.ses ranging fromgr. xv togr.lx (1-4 grams) three 
or four times a day. 

Acid Sodium Sulphite, NaHSOs. — The salt is official 
in the United States Pharmacopoeia as Sodii Bisulphis, 
Sodium Bisulphite. It occurs in opaque, prismatic 
crystals, or a crystalline or granular powder, and on 
exposure to air slowly oxidizes and becomes the 
sulphate. The salt has an odor of sulphur dioxide 
and a disagreeable, sulphurous taste. It dissolves 
in 3. .5 parts of water at 2.5° C. (77° F.), in two parts 
of boiling water, in seventy parts of alcohol at 25° C. 
(77° F.), and in forty-nine parts of boiling alcohol. 
It should be kept in small vials, well stoppered 
and well filled. 

This sulphite is less stable than the normal sodium 
salt, and more disagreeable to taste. In other 
respects it is similar. 

Normal Sodium Thiosidphale, Na-. S5O3 -t- 5H;0. — 
The salt is official in the United States Pharmacopoeia 
under the title of Sodii Thiosulphas, Sodium Thiosul- 
phate. The confusion in the use of the term hypo- 
sulphite arises from the fact that before the discovery 
by Schiitzenberger of what is now, and properly, 
called hyposulphurous acid — namely, the body HjSOj 
— the name in question was applied to thiosulphuric 
acid (H2S2O3). Hence it comes about that though a 
true sodium h^^posulphite is known, the salt that 
formerly passed current by that name was not a 
hyposulphite, but a thiosulphate. Sodium thiosul- 
phate occurs as large, colorless, transparent, mono- 
clinic prisms, or plates, which effloresce in dry air of a 
higher temperature than 33° C. (91.4° F.). It is 
odorless, with a cooling, bitter, and somewhat sul- 
phurous taste. It dissolves in 0.35 part of water 
at 25° C. (77° F.). In boiling water it decomposes 
rapidly. It is insoluble in alcohol. It should be kept 
in well-stoppered bottles. 

Sodium thiosulphate is more stable than the sul- 
phites, undergoing decomposition by acids less easily. 
In properties, uses, and modes of administration it 
resembles sodium sulphite. The internal dose is 
generally from gr. xv to gr. xx (1.0-1.3). 

Besides the foregoing, potassium sulphite and 
magnesium sulphite have been used in medicine, 
but are out of vogiie and not now official in the 
United States Pharmacopoeia. They are, medicinally, 
duplicates of the sodium salts. 

Edward Curtis. 
R. J. E. Scott. 



Sulphonmethanuin, U. S. — Sulphonmethan, Sul- 
phonal, B. P. (Dimethyt-methanc-dicthyl-sut phone) 
(CH,).C(S02C;H61;. It fomis in colorless, odorless, 
and nearly tasteless prismatic crystals: soluble in 360 
parts of cold water and 15 parts of boiling water. It 
is soluble in 47 parts of alcohol. 

Professor Kast introduced it in ISSS as an hypnotic, 
and it has proved so efficacious that it is now recog- 
nized as one of tlie best drugs we possess for that pur- 
pose. It is durely a soporific, and is rarely employed for 
any other purpose than to procure sleep. It does not 
influence the body temperature, it has no antiseptic 
qualities, and as an analgesic is of no practical value. 



19 



SulplioiiiiK'lliaiiuin 



RKFERENCE HANDBOOK OF THE MEDia\L SCIENCES 



The action of sulphonal is directed to the central 
nervous .system as a sedative, inducing a quiet and 
cahn sleep from which the patient awakens refreshed. 
In the case of animals, when excessive doses are niven 
the sleep deepens into coma, convulsions, and paral.v- 
sis. Its sedative action extends to the spinal cord, 
lessening reflex action. In animals the loss of power 
in the hind limbs may be an early symptom. After 
absorption sulphonal is decomijosed in the system and 
excreted in the urine in the form of sulphur com- 
pounds. Some observers have reported the pre.sence 
of pure sulphonal in the urine after its free adminis- 
tration. At times sulphonal proves irritating to the 
kidney, causing lessoned secretion and pain. 

Sulplional has proved of greatest service where the 
insomnia isof purely nervous origin, as in neurasthenia, 
mental depression" overwork, and worry, and has 
found a field of great usefulness in the various forms 
of mental disease. When pain is the cause of the 
sleeplessness, its good effects are greatly modified, but 
in many forms of neuralgia and pain of a reflex char- 
acter it may be used with success. Where pain is due 
to organic disease it has no influence whatever. In 
the insomnia of acute and chronic disease, and during 
convalescence from di.soase, it is of much benefit, but 
reciuires to be given with some caution, particularly 
when there is much debility or prostration, and in the 
aged. In the sleeplessness of cardiac disease and of 
other forms of organic or mechanical derangement, it 
is not of much use. In delirium tremens it has been 
mudi used, in many instances with benefit, but in 
these eases the effect is uncertain, and the do.se re- 
quired is excessive and approaching the limit of its 
physiological action. 

As an hypnotic, the dose is from fifteen to thirty 
grains. It is usual to commence with fifteen grains 
and increase the quantity until the proper effect is 
produced. Ten grains will often be sufficient in the 
aged and debilitated, or where the insomnia is of a 
mild degree. Under ordinary conditions thirty grains 
is a perfectly safe do.se, and this quantity is usually 
required to produce its full hypnotic action. On ac- 
count of its insolubility the action is slow, and the 
dose should be administered at least one hour before 
bedtime in hot solution. 

The .sedative action of sulphonal on the spinal cord 
and nerve centers has led to its use in some nervous 
troubles. In chorea it has been given to children in 
doses of from two to five grains, and has been followed 
by a fair percentage of successes. In old-standing 
cases it has little or no influence. 

It is now fully recognized that sulphonal is not 
without its toxic action, and numerous fatal cases 
have followed its employment. The simplest symp- 
toms that may arise include drowsiness and stupor, 
giddiness, vertigo, ataxia of tlie tongue and muscles 
of the throat and face, and of the extremities. These 
.symptoms gradually disappear after an interval of 
from ten to twelve hours, without leaving any ill 
effects. The more .severe symptoms are profound 
coma, muscular twitchings, paralysis of sphincters, 
hallucinations, delirium, anuria, great prostration. 

The fatal cases that have been reported were due to 
overdoses or to the prolonged use of the drug. 

Be.\umont Sm.\li-. 



Sulphur. — Sulphur is used in medicine in the 
condition of fine powder, three .styles of which arc 
official in the United States Pharmacopoeia, as 
follows: 

SuLPunR ScBLiM.^TUM, Sublimed Sulphur. — This 
preparation, commonly called flou-ers of sulphur, is 
crude sulphur purified by distillation in an apparatus 
so arranged that the vaporized sulphur shall condense 
in the form of a powder upon the walls of the receiving 
chamber. Sublimed sulphur is a fine, citron-yellow 



powder, of a slight, characteristic odor, and generally 
of a faintly acid taste and an acid reaction. It is 
insoluble in water or alcohol. When ignited, it 
burns with a blue flame, forming sulphur dioxide gas. 
Sublimed sulph\ir always contains a little suli)luuic 
acid, whereby it is unfitted for internal mcilicinul 
use. 

Sdlphur Lotum. — Washed Sulphur. — This prepara- 
tion is simply sublimed sulphur freed from contaminat- 
ing sulphuric acid. The sulphur is digested for three 
days with diluted ammonia water, by which process 
the sulphuric acid is fixed as ammonium suljjliate, 
and the mass is then thoroughly washed with water 
upon a muslin strainer. The ammonium sidphatc^ 
is thus washed away, and the purified sulphur is 
finally dried at a gentle heat, and passed through a No. 
30 sieve. Washed sulphur is a fine, citron-yellow 
powder, odorless and almost tasteless, insoluble in 
water or alcohol. When derived from a sulphur 
originally obtained from metallic sulphides, washed 
sulphur may contain the very dangerously con- 
taminating substance, arsenic, in the form of the 
trioxide or trisulphide of that element. Proof of 
absence of arsenic is afforded by digesting a samjilc of 
washed sulphur with two parts of ammonia, filtering, 
and finding the filtrate unaffected by supersaturation 
with hydrochloric acid, and not precipitated by 
passing through it a stream of hydrogen sulphide. 

Sulphur Pr.ecipitatum, Precipitated Sulphur. — 
This preparation, formerly known as milk of .':ulp)iur, 
is an exceedingly fine powder of sulphur, gotten by 
precipitating with diluted hydrochloric acid a solution 
of sulphur salts of calcium, obtained by mixing sub- 
limed sulphur and slaked lime with water. The 
sulphur, after precipitation, is collected upon a 
strainer, thoroughly washed with water, and dried at 
a gentle heat. Precipitated sulphur is a very fine, 
yellowish-white, amorphous powder, odorless and 
almost tasteless, insoluble in water or in alcohol. 
Precipitated sulphur should stand the same tests for 
absence of free acid and of contaminating arsenic as 
washed sulphur (see above). This variety of sulphur 
powder differs from the foregoing in being lighter in 
color and of finer particles. From the latter fact 
it derives the advantages of greater smoothness and 
readiness of mixing with fluids; but, to offset, it has 
the disadvantage of tending to develop an acid upon 
keeping. 

Sulphur is insoluble in water and practically so in 
alcohol, but dissolves in varying proportions in solu- 
tions of the alkalies and in oils, fixed and volatile. 
Because of its insolubility in aqueous fluids, sulphur is 
practically devoid of physiological activity while under 
its own form, but, when rubbed in ointment upon the 
skin or when taken internally, a feebly irritant action 
appears, presumably due to a sulphide formed in 
small quantity by the chemicals present in the 
secretions of the part. What little of an internally 
taken dose of sulphur is absorbed is also probably 
in the condition of a sulphide, and the constitutional 
effects that follow are a feeble reflex of those of the 
alkaline sulphides (see Sulphides). In single, con- 
sideraljle dose the local irritation displayed by sulphur 
determines increased intestinal activity, showing 
itself by relaxation of the bowels, but this with but 
little increase of secretion. The stools are therefore 
generally composed of solid or semi-solid fecal matter, 
and the operation of the medicine is mild and slow, the 
call to stool rarely occurring until from six to eight 
hours after the taking of the sulphur. If haliitually 
used as a laxative, sulphur may induce a low catarrli 
of the alimentary tract. A disagreeable feature of its 
internal taking for anj' purpose is the tendency to the 
generation of flatus, offensive from the presence of 
sulphurcted gases. 

The therapeutic applications of sulphur are as follows. 
By some it is given internally as a means of getting 



20 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



Sulphur Springs 



the constitutional effects of the sulphides in consti- 
tutional diseases, but by the majority of practitioners 
the internal use is in laxative dose only, for a laxative 
eflfect. Such dose is from 3i-iij (4.0-12.0), the 
washed or precipitated preparations being selected, 
arfd the powder mixed with molasses or diffused in 
milk for the taking. Externally, ointments contain- 
ing sulphur are a good deal used as mildly irritant 
applications in skin diseases generally, and, specifi- 
cally, as efficient parasiticidal dressings in itch. 
The following ointment is official in the United States 
Pharmacopoeia : 

Unguentum Sulphuris. Sulphur Ointment. — This 
preparation is compounded of 150 parts of washed 
sulphur and 850 of benzoinated lard, thoroughly 
incorporated. It may be applied without dilution, 
and is a very commonly used ointment for the 
treatment of the itch. It has a disagreeable sul- 
phureted smell, which may to a certain degree be 
masked by the addition of a little of some odoriferous 
volatile oil. Edward Curtis. 

R. J. E. Scott. 



Sulphur Dioxide (formula SOj). — This compound, 
commonly miscalled .'nil/ih Kraiis acid gas, is the product 
of the comljustion of sulphur in air. It is a colorless 
gas, of a well-known characteristic "sulphurous" 
odor, and is both offensive to the nostrils and intensely 
irritant to the larynx. Even the fumes of a single 
burning sulphur match-head easily excite coughing, 
and air highly charged with the gas is fatal to life. 
Sulphur dioxide dissolves freely in water — in one- 
fiftieth of its volume at ordinary temperatures — 
forming in the process of solution an acid body. 
sulphurous acid proper (H-SO3). (See Sulphurous 
Acid.) 

The medicinally valuable property of sulphur 
dioxide is its peculiar noxiousness to the vitality of 
disease germs — a germicidal potency in which this 
compound, among gases, is rivalled only by formal- 
dehyde, chlorine, and the vapors, respectively, of 
bromine and of iodine. (See under Disinfeclatits.) 
Edward Curtis. 
R. J. E. Scott. 



Sulphur Iodide. — Under the title Sulphuris 
lodidum, Sulphur Iodide, the United States Phar- 
maccipci'ia recognizes a preparation made by fusing 
by lieat a mixture of one part of washed sulphur and 
four parts of iodine. The fused mass, after cooling, 
is broken into pieces and kept in glass-stoppered 
bottles. These lumps are grayish black in color and 
have a metallic luster. They have the odor of 
iodine and an acrid taste. The substance is prac- 
tically insoluble in water, but dissolves in about 
sixty parts of glycerin, .\lcohol and ether dissolve 
out the iodine and leave the sulphur. On exposure 
to the air, also, iodine is gradually lost. 

This substance is differently regarded by chemists, 
some considering it a definite compound, correspond- 
ing to the formula S2I2, and others thinking it more 
probalily a mere physical mixture. If a true chemical 
compound, it is one of exceptional instability, as the 
foregoing narration of its properties makes evident. 
To the therapeutist it presents itself practically as a 
joint representative of free sulphur and free iodine. 
It has occasionally been given internally for the 
purposes for which iodine is so administered, but the 
commoner employment is external as a gentlj* irri- 
tant, iodized application in various skin diseases. It 
is best applied in the form of ointment made with 
lard, containing the sulphur iodide in the proportion of 
about ciglit per cent. Edw.\rd Curtis. 

R. J. E. Scott. 



Sulphur Spring (Cold Sulphur Spring). — Rock- 
bridge County, Virginia. 

Post-Office. — Goshen. Hotel. 

Access. — Via Chesapeake and Ohio Railroad to 
Goshen, thence by -stage two miles to springs. 

The Cold Sulphur Spring is located in the moun- 
tains of Virginia, at an altitude of 2,000 feet above 
the sea-level. The .spring is near the center of the 
celebrated mineral-spring region, so long noted for the 
beauty of its scenery and the salubrity of its climate. 
On every side are lofty mountains of rare loveliness 
and grandeur, and the beautiful lawn with its shade 
of primeval oaks, forms a picture of alluring restful- 
ness and tranciuillity. Within a few minutes' drive 
is the west entrance to the Go.shen Pass, the gate- 
way through which the north branch of the James 
River finds its way to the sea — a spot famous for 
its wild and magnificent scenery. 

The water of the Cold Sulphur Spring is clear and 
slightly sparkling from the gases which it contains. 
It has a temperature of 50° F. as it flows, and the 
presence of a large amount of free carbonic acid gas 
renders it peculiarly light and grateful both to the 
taste and to even a delicate stomach. The following 
analysis of the water has been made: 

Calcium bicarbonate 1 .84 

Magnesium carbonate 1 . 78 

Iron carbonate . 02 

Sodium sulphate 2.40 

Calcium sulphate 2.91 

Lithia Trace 

Aluminum sulphate . 25 

Magnesium sulphate 0.29 

Phosphates Trace 

.Sodium silicate 1 .48 

Calcium chloride 0.12 

Volatile matter . 32 

This analysis shows a mild alkaline-chalybeate. 

The effects of the water are tonic and sedative. 
It is used with good effects in various conditions 
among which are diseases of the stomach, bowels, 
liver, and kidneys; diseases of women, nervous affec- 
tions; gout, rheumatic affections, and skin diseases. 
Emma E. Walker. 



Sulphur Springs (Bronson). — Vigo County, In- 
diana. 

Post-office. — Terre Haute. Sanatorium. 

Access. — Via Cleveland, Cincinnati, Chicago and 
St. Louis, Evansville and Terra Haute, and Terra 
Haute and Indiana Railroads. 

The water from the well that is used for all baths 
comes from a depth of 1865 feet. 

The following analysis has been made by W. \. 
Noyes, Professor of Chemistry in the Rose Poly- 
technic Institute: 

Grains to 
r. S. Gallon. 

Silica 0.706 

Alumina 0.05.3 

Iron bicarbonate 0.035 

Strontium chloride trace 

Calcium chloride 12.941 

Calcium sulphide 1 . 197 

Calcium sulphate . 257 

Calcium bicarbonate 19.927 

Calcium phosphate trace 

MaRnesium chloride 11. 055 

Magnesium bicarbonate 15.344 

Lithium chloride more than a trace 

Potassium chloride 3 . 625 

Borax more than a trace 

Sodium iodide trace 

.Sodium bromide more than a trace 

Sodium chloride 301.258 

Hydrogen sulphide 4 . 629 

Total 371 027 



21 



i<ulpliur Springs 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



The best hotel iircomiiiiMiatioiis have been provided. 
The water is used for drinking and batliing and has 
proved beneficial in the treatment of rheumatic 
troubles, neuralgia, diseases of the stomach, kidney, 
liver, and skin. E.mm.\ E. W.-vlker. 



Sulphuric Acid.— Oil of Vitriol, H.SOi. This 
well-known acid is official in the United States Phar- 
macopoeia under the title Acidum Sulpliurirum, Sul- 
phuric Acid, and is defined to be "a licpiitl. composed 
of not less than 92.5 per cent, of absolute sulphuric 
acid, and about 7.5 per cent, of water" (U. S. P.). 
Sulphuric acid is a heavy liquid of an oily appearance, 
colorless when newly made, but apt to acquire a 
smoky hue upon kcejjing. The s])ecific gravity varies 
in different samples, but a gravity of not below 1.826 
at 25° C. (77° F.) is recognized as standard by the 
United States Pharmacopoeia. The acid has an 
intense affinity for water. Mixed with that fluid, it 
unites therewith with the evolution of considerable 
heat and with a contraction of volume, forming a 
clear solution. By reason of the same affinity, many 
organic bodies are decomposed upon treatment with 
sulphuric acid, the acid abstracting from their mole- 
cule the elements of water. Thus, by dehydration, 
oxalic acid is chemicallj' broken up, alcohol is con- 
verted into ethylene gas (C^Hi), wood and sugar are 
blackened, and textile fabrics and animal tissues are 
destroyed. Sulphuric acid, if diluted, also attacks 
most of the common metals, the prominent exceptions 
being gold, platinum, and iridium. Certain of the 
metals, such as copper, mercury, antimony, bismuth, 
tin, lead, and silver, are also acted upon by the con- 
centrated acid, if the same be heated. 

Upon the living animal system strong sulphuric acid 
acts purely as a powerful caustic. Its action is a 
spreading one, and the sloughs have a dusky or 
blackish hue, quite different in color from the yellow 
sloughs produced by nitric or hydrochloric acid. 
Swallowed in any quantity, the strong acid is an 
intense corrosive poison. 

Therapeutically, strong sulphuric acid is occasion- 
ally used as a caustic, but the very intensity of its ac- 
tion is in its disfavor, so that nitric acid is generally 
preferred. The acid must be kept in glass-stoppered 
bottles. 

Diluted, so as not to be corrosive, sulphuric acid, 
like all sour acids, tends to check acid, and to increase 
alkaline secretions, to inhibit fermentations, and, of 
course, to neutralize alkalinity. Dilute preparations 
of sulphuric acid are, therefore, available to repress 
morbid sweatings, both applied locally as lotions, and 
given internally to allay thirst and quicken appetite; 
to prevent fermentation of food in the primw vi(r. and 
so to cure diarrheas due to the irritation of the prod- 
ucts of such fermentations, and to neutralize the 
alkali of alkaline pyrosis. For these various purposes 
tlie following official preparations of the United 
States Pharmacopoeia are available: 

AcmcM SuLPHDRicu.M DiLUTUM, Diluted Sulphuric 
Acid. — This preparation is a simple aqueous dilution 
of sulphuric acid, of ten-per-cent. strength. It is a 
colorless fluid, intensely sour of taste, and of about the 
specific gravity 1.067 at 25° C. (77° F.). It should be 
kept in glass-stoppered bottles. This grade of acid, 
although not corrosive, is quite irritant, and, for 
medical use, requires considerable further dilution. 
The dose is from ten to thirty drops, diluted thirty- 
or fortyfold, and to be taken through a tube, with the 
mouth well rinsed after the swallowing. 

Acidum ScLPHunicuM Ahom.\ticum, Aromatic Sul- 
phuric Acid. — This preparation consists of alcohol 
charged with sulphuric acid and tincture of ginger, 
and flavored, in addition, with a trace of oil of cinna- 
mon. It contains about twenty per cent., by weight, 
of sulphuric acid. The preparation is a limpid, yellow 

22 



fluid of an aromatic, ethereal, and strongly sour taste, 
and of specific gravity about 0.933 at 25° C. (77° F.). 
.•\s its odor suggests, it probably contains some ethe- 
real product of a reaction between the acid and alco- 
hol of its composition. Aromatic sulphuric acid 
should be kept in glass-stoppered bottles. 

This preparation is tlie favorite one for the internal 
administration of sulphuric acid. It is to be given in 
the same manner as the dilute acid (see above), and in 
the same or somewhat smaller doses. 

Edward Cdrtis. 

R. J. E. SroTT. 

Sulphurous Acid. — H^SOs. Sulphur dioxide gas 
(SO;) is readily absorbed by water, and in so dissolving 
is to be regarded as uniting with water, molecule for 
molecule, with the formation of the acid body, II2SO3. 
The United States Pharmacopoeia recognizes under 
the official title Acidum Sulphurosum, Sulphurous 
Acid, an acid representing not less than six per cent., by 
weight, of sulphur dioxide, and of specific gravity not 
less than 1.028 at 25° C. (77° F.). Sulphurous acid is 
a colorless fluid, smelling pungently of sulphur dioxide, 
and tasting both sulphurous and sour. It has a strong 
acid reaction, and first reddens and then bleaches 
litmus paper. It is wholly volatilized by heat, and 
tends constantly to undergo conversion into sulphuric 
acid by the absorption of oxygen. This change is 
hastened by the action of light, hence the Pharmaco- 
pa'ia directs that sulphurous acid be put up in glass- 
stoppered, dark amber-colored bottles, and be kept in 
a cool and dark place. The pharmacopcrial process 
for making the acid is to generate sulphur dioxide by 
heating a mixture of sulphuric acid and charcoal, and 
to conduct the mixed sulphur and carbon dioxides 
into distilled water. The sulphur dioxide dissolves 
in the water with the formation of sulphurous acid, 
and the carbon dioxide mostly escapes. 

In its medical properties sulphurous acid resembles 
sulphur dioxide (see Sulphur Dioxide), and may prac- 
tically be regarded, indeed, as a simple aqueous solu- 
tion of that compound. It is a pretty potent germi- 
cide, and upon tender surfaces of the animal body is 
decidedly irritant. It bleaches vegetable colors. 
The acid is used, externally, as a wash in parasitic 
skin diseases, generally diluted two- or threefold, 
and, internally, is occasionally prescribed in cases of 
pyrosis and sarcinae. It is, however, an exceedingly 
disagreeable medicine to take. The dose is thirty 
minims (2.0) of the official acid, taken in a wineglass- 
ful of water. Edward Curtis. 

R. J. E. Scott. 

Sumbul.— U. S. P. (Sumbul Radix, B. P., Miisk- 
Tool). The dried rhizome and root of an undetermined 
plant, probably of the family Umbelliferw. This 
large perennial herb, belonging to the asafetida-, 
galbanum-, and ammoniacum-yielding group of the 
family, and inhabiting the same general region, has 
a large, rather short cylindrical root, attaining a 
diameter of four or five inches, and a length of say a 
foot, when it divides into several stout branches. 
The root itself, as a perfume and afterward as a 
medicine, appeared in Europe about 1840. 

Sumbul occurs in transverse segments, varying in 
diameter from about two to seven centimeters, and in 
length from fifteen to thirty millimeters; light, spongy, 
annulate or longitudinally wrinkled; bark thin, brown, 
more or less bristly fibrous; the interior whitish, with 
numerous brownish-yellow resin dots and irregular, 
easily separated fibers; odor strong, musk-like; taste 
bitter and balsamic. 

Constituents. — The most important constituent is 
the Tesi7i, of which there is nine per cent. (Fliickiger); 
it has a musky smell, more developed in contact with 
water, and a bitter, aromatic taste. The root con- 
tains also a small quantity of dull bluish-colored oil. 



REFEREN'CE HANDBOOK OF THE MEDICAL SCIENCES 



Sunimervllle, S. C. 



Action and Use. — Sumbul has not any important 
medicinal value; like asafetida, and its namesake, 
musk, it is gently stimulant and slightly antispas- 
modic, and may be given for the same nervous 
conditions as they; but its principal employment is 
in the preparation of some perfumes, where it takes 
the place of musk. A tincture [Tinclura Sumbul, 
strength one-tenth) is official. Henry H. Rusby. 



Summerville, S. C. — This popular winter resort, 
among the pines, is situated in the southeastern 
portion of the State, twenty-two miles northwest 
from Charleston. Its favorable features as a health 
resort are its dry sandy soil, pine forests, equable mild 
temperature, and freedom from the enervating heat 
peculiar to points farther south. The pines are an 
especial feature of the place, and abound not only 
about the town but are thickly scattered throughout 
it "in the middle of the streets on the sidewalks, in 
the gardens, and in fact everywhere." There are 
local laws prohibiting the cutting down of these 
trees. The atmosphere is permeated with their 
balsamic odor, and if there is any virtue in such a 
naturallj' medicated air it must surely be found here. 

The population of the town is about 2,500 souls, 
and there are various churches, schools, shops, good 
markets, etc. 

The sanitary condition is carefully supervised by 
an efficient board of health. Tuberculosis is in- 
cluded in the list of contagious or infectious diseases 
required to be reported to the board, and whenever 
in a hotel or any other building a case of consump- 
tion has, "lived, resided or died," it must be reported 
in writing to the secretary of the board of health; 
and "immediately upon receipt of each report, the 
health officer shall, at the expense of the occupant or 
owner of the premises, cause said premises to be at 
once fumigated and properly disinfected." [Extract 
from the Rules and Regulations of the Board of 
Health.] 

The natural drainage is excellent, and this is sup- 
plemented by an open canal, on one side of the town, 
some miles in length, and into this accessory canals or 
ditches empty. Soil carts are also employed by the 
town. 

The water supply is very generally derived from 
open wells, although the Pine Forest Inn and Pine- 
hurst (Tea Farm) have artesian wells. 



The accommodations are good, there being several 
first-class hotels and many boarding-houses. 

The outdoor attractions and amusements are walks 
and drives among the pines, golf, many excursions 
in the vicinity to various historic and ancient land- 
marks — old churches, plantations, and the like — 
the Pinchurst Garden Park, with its large variety 
of ornamental trees and shrubs, and the Pinehurst 
Tea Gardens where the tea plant is successfully grown. 
Twenty-two miles distant is Charleston, with all its 
attractions in and about the city. There are also 
opportunities for shooting and fi.shing. 

The subjoined meterological table affords an index 
of the various climatic features. It will be seen that 
the winter temperature is comparatively mild, the 
mean maximum and minimum temperatures not 
extreme, and a large majority of the days are sunny, 
so that one can be out of doors the most of the time. 
The mean average annual rainfall for nineteen years 
was 56.76 inches, and for the four years of the chart, 
59.16 inches. On account of the character of the soU 
the ground is quickly dry after the heaviest rainfall. 
The average relative" humidity appears high, but it is 
said that there is no sensation of dampness In the 
atmosphere. According to Dr. W. H. Prioleau, of 
Summerville (Therapcuiic Gazette, September, 1897), 
the climate is most beneficial to invalids from October 
to May, "for during that time there is bright sunny 
weather, and the atmosphere changes are seldom so 
sudden as to cause any serious anxiety or discomfort." 
"The town is near enough to the sea coast," says 
the same authority, "to cause the atmosphere to 
lose the aridity of a sandy plain; at the same 
time sufficiently distant to be free from all damp- 
ness." 

The diseases and conditions for which this climate 
is suitable are pulmonary tuberculosis in the early 
stage, laryngitis, bronchitis, asthma, influenza, neu- 
rasthenia, and insomnia. Further, it is a favorable 
place for a winter residence for the many who, for 
one reason or another, desire to escape the cold of the 
North or West. "I must admit," says Elizabeth 
Stuart Phelps, writing in McChire's Magazine, "that 
Summerville is a land of lovely dreams, with more 
conveniences and fewer discomforts, more tonic and 
less enervation than any other Southern health or 
pleasure resort I have seen. Roses run riot over it; 
its homes are gardens, and gardens are its homes. 
There the winds are laid. . . . There it is always 



Cli.mate op Summerville, S. C. — Period of Observation from Jaitoary, 1899 to Jantiary, 1903.* 



No- 
vember. 



December. 


January. 


Feb- 
ruary. 


March. 


April. ■ 


47.5° 


46.8° 


46.6° 


54.4° 


59.2° 


74.7 


74.8 


70.2 


81.2 


83.7 


19.0 


21.4 


16.7 


27.6 


34.7 


58.7 


58.4 


56.3 


67.7 


68.1 


46.2 


36.8 


37.1 


44.9 


50.2 


12.5 


21.6 


19.2 


22.8 


17.9 


55.0 


53.4 


57.4 


53.6 


49.0 


78.8 


70.8 


70.9 


72.5 


73.0 


3.73 


3.49 


4.67 


3.01 


4.08 


S.W., N.E. 


S.W. 


S., N.W. 


S.W. 


S.E. 


15.0 


13.0 


10.4 


13.4 


15.7 


7.5 


9.2 


10.0 


11.2 


9.2 


22.5 


22.2 


20.4 


24.6 


24.9 


8.2 


8.8 


7.6 


6.4 


5.0 



July. 



Temperature — Di 
Average mean. 
Average maxiii 



Mean minimum 

Average daily range. . . . 
Average monthy range . 
' iiiity— 



59.3° 
79.5 
29.5 
66.5 
51.2 
15 3 



.77 



N.E. 



Hu 

(The humidity was recorded only 

tion of the period.) 
Average relative, per cent 

Precipitation — 

Average in inches 

Wind- 
Prevailing direction 

Weather — 

Average number of clear days 18.2 

.\verage number fair days 

Average number clear and fair days 24.9 

Average number cloudy days 5.0 



Frost occurs from November to April, with ice and occasional snow in the coldest month of the year. 
• These data were obtained through the kindness of Dr. A. H. Hayden, of Summerville. S. C. 



80.1° 


72.5° 


96.2 


91.0 


65.2 


53.5 


88.3 


82.7 


71.2 


65.2 


17 1 


17.5 


31.0 


37.5 



S.W. 

15 2 
12.5 
27.7 
3.2 



79.5 

3.56 

N.E. 

19.7 
5.2 



59.16 
N.E., S.W. 



23 



SunimorvUle. S. C. 



REFERENCE HANDBOOK OF THE MEDIC.\L SCIENCES 



dreamland, and there the knotted Northern nerves 
mav relax and rest." 

One can reach Summerville by various railroad 
routes or bv water from New York to Charleston 
and from thence by rail. The time from New York 
by rail is twenty-four hours. Edward O. Otis. 



Superfetation. — Ordinary multiple pregnancy is 
generally the result of the simultaneous fertilization of 
more than one ovule. Should such fecundation be 
successive instead of simultaneous, it is called super- 
impregnation. Of this, there are two varieties: (1) 
Superfecutidation, which occurs when two (or more) 
ovules belonging to the same period of ovulation 
are impregnated by successive acts of coitus. (2) 
Superfetation, which occurs when two or more ovules 
belonging to successive periods of ovulation are im- 
pregnated, so that a woman who is already pregnant 
becomes again pregnant a month or more later, and 
carries simultaneously in the uterus both these prod- 
ucts of conception. Thus a second ovum is fertilized 
after the first has been developing for a month or 
more, and the two fetuses continue to develop simul- 
taneously and independently. 

The term superimpregttation has been used in two 
senses: (1) as a generic term including both super- 
fecundation and superfetation; and (2) as synonymous 
with superfetation or superfecundation. We believe 
the former to be the more correct usage, though the 
term might well be abolished. 

Superfecundation is now well recognized, and needs 
no discussion. There have been reports of too many 
well-authenticated cases to allow of any doubt on this 
point. The most conclusive proofs are furnished by 
those cases in which a black woman has at the same 
time given birth to twins, of different colors, the one a 
mulatto and the other black, and whoso features 
have unmistakably indicated their paternity. In 
many of these instances the mother has explained that 
both a white man and a black man had had intercourse 
with her within a short interval of eaoh other. Similar, 
but not so frequent, are the reported cases in which a 
white woman h.as had intercourse successively with a 
white man and a black man, and has given birth to 
twins of different colors and races. Illustrative cases 
in abundance may be found in the pages of works on 
medical jurisprudence, notably those of Tidy and 
Beck. 

Rut superfetation was not so readily admitted. 
Like other theories which have subsequently crystal- 
lized into facts and been accepted, the possibility of 
superfetation was alternately asserted and denied. 
Thus, according to Beck, Brassavolus, who lived 
between 1500 and 155.5, said that he had known super- 
fetation to be epidemic! By later physicians, the pos- 
sibility of superfetation was generally accepted, and 
many cases were brought forward to support the 
claim; but it is doubtful how many of these cases 
would stand the test of a thorough investigation at 
the present day. The next stage was that of vigorous 
denial. This view was taken by Lusk, wliQ says: 
"That impregnation can take place at two periods 
distant from one another — must be regarded as an 
inadmissible hj'pothesis, until physiologists shall 
succeed in demonstrating in a single instance, by the 
presence of corpora hitea of different ages, that ovula- 
tion ever occurs during pregnancy." No doubt ovula- 
tion does ordinarily cea.se during pregnancy; and this 
maj' be one of the reasons why there are so few cases 
of superfetation. But that ovulation can occur dur- 
ing pregnancy was demonstrated by Christopher, 
who also cited Slavjansky's case. An apparently un- 
assailable case is one reported by Cosentino: "A 
woman in the sixth month of pregnancy died of 
heart disease. The ovaries were subjected to a care- 
ful microscopic examination, and in them were 
found follicles in all stages of development; also 

24 



one ruptured follicle of a diameter of fifteen milli- 
meters with ragged margins and a rich arterial and 
venous network surrounding the theca foUiculi. Be- 
tween the granular layer and a lot of detritus a 
perfectly mature ovum with all of its elements was 
found" (quoted by Herzog). 

At the present day, both the possibility and the 
probability of superfetation are fully admitted; that it 
is of frequent occurrence, or that the majority of the 
cases formerly reported under this heading are cor- 
rectly designated, is not conceded. It must be re- 
membered that superfetation is neither normal nor 
physiological ; it is a pathological condition. In an or- 
dinary normal pregnancy we note the following (among 
other") characteristics: (1) It is single; (2) it is intra- 
uterine; (3) menstruation and ovulation both cease; 
(4) the uterus is neither bifid nor septate, but single. 
Now, variation in any of these conditions may pro- 
duce pathological or abnormal results; and superfeta- 
tion is one such pathological variation. The possible 
results of superfetation are two: either two children 
equally well developed, but born at different times; or 
the birth of twins, one of which is developed and the 
other not. Those who deny the possibility of super- 
fetation have explained these conditions as being due 
either (1) to an ordinary twin pregnancy, or a super- 
fecundation, in which one fetus was "crowded, or 
for some other reason did not obtain adequate nutri- 
tion during gestation, and was therefore not properly 
developed; or (2) to an ordinary twin pregnancy or 
superfecundation in which one ovum became blighted, 
and possibly suffered compression and partial mum- 
mification { = fetus papyraceus); or (.3) to a bifid 
uterus, in w-hich one ovum was developed in each 
half. The possibility of superfetation occurring in a 
normal uterus is extremely doubtful. 

There can be no doubt that many of the earlier 
reported cases of superfetation can be explained as 
above; but there still remain some that are intelligible 
only on the ground of superfetation. Thus, where 
viable children are born at an interval of four rnonths, 
and the uterus is not double, there is at present no 
explanation to be offered beyond the one that forms 
the subject of this article. Tidy, in his "Legal Medi- 
cine," quotes one such ease from Naphey: "Mary 
Anne Bigaud, at thirty-seven, gave birth, on April 
30, 1748, to a full-term mature boy, which survived 
its birth two and one-half months, and to a second 
mature child (girl) on September 16, 1748, which 
lived for one year. The mother was proved after 
her death not to have had a double uterus. (This 
case is vouched for by Professor Eisenman, and by 
Leriche, surgeon-major of the Strasbourg Military 
Hospital.)" Several such cases are .also given by 
Bonnar (Edin. Med. Jour., January, 1865), "cases 
that prove, as far as anything of the sort can prove, 
that superfetation is a positive fact." 

R. J. E. Scott. 



Suppositoria. — In common parlance the word 
suppository (Supposilorium) means a properly shaped 
plug of rnedic.ated material, intended for insertion 
into the rectum, urethra, or vagina, with the design of 
having this plug, after insertion, liquefy by the 
warmth of the part, and so set free a contained medica- 
ment. By custom, however, a urethral or a vaginal 
suppository is, respectively, so designated specifically, 
and the word "suppository," unqualified, is held to 
refer to a rectal suppository only. The United 
States Pharmacopoeia, under the title Suppositoria, 
Suppositories, gives a general direction only for the 
making of a plug intended for use as a rectal sup- 
pository, leaving it to the prescriber to order the 
active ingredient to be incorporated with the same. 
By such pharmacopoeial direction, the suppository 
is made up, in substance, ot oil of Iheobroma ("cacao 
butter") or glycerinaled gelatin and weighs about 



REFERENXE HANDBOOK OF THE MEDICAL SCIENCES 



Suprarenal Glands, Anatom}- 



two grams in the case of rectal and urethral 
suppositories; and about four grams in the case 
of vaginal suppositories when made with oil of theo- 
broma, and about ten grams if made with gly- 
cerinated gelatin. The special medicament is to be 
mixed with the oil of theobroma, melted by heat, and 
the mixture then run into elongated cylindrical, 
conical or globular moulds, according to the kind of 
suppository. Oil of theobroma is specially adapted 
for a suppository basis, since it is at once bland, hard 
at ordinary temperatures but readily liquefied by the 
temperature of the body, because it combines the 
qualities of medicinal inertness and hardness at 
ordinary temperatures with ready capability of lique- 
faction at the temperature of the recta! cavity. In 
the administration of a rectal suppository the points 
should be ob.served to clean out the rectum before 
insertion, and, in the inserting, to push the suppository 
well pa.st the sphincter. There is one suppository 
olRcial in the United States Pharmacopoeia, and one 
in the National Formulary. 





Composition. 


SCPPOSITOBIA 


BOROGLV- 


X.F. Glycerinated gelatin 1.25 gm.. 


CEBINI 




Boric acid 0.33 gm.. Glycerin 


(Suppositorie 


s of Boro- 


1.45 gm.. Water 1.1 gm. 


glycerin). 






SuPPOSITORt.4 


Oltcerim 


U.S.P. Glycerin 3 gm., Monohydrated 
sodium carbonate 0.05 gm.. 


(.Suppositorie 


3 of eLv- 


Stearic acid 0.2 gm.. Water 


ccrin). 




0.5 CO. 



R. J. E. Scott. 



Suprarenal Glands, Anatomy of. — The supra- 
renal glands or adrenals are two ductless glands, that 
is, they form a secretion that is taken up directly by 
the blood-vascular or lymph-vascular system. They 
belong to the chromophil system, a series of glandular 
organs mostly of small size that produce or discharge 
adrenin. Tliey are called chromophil because the 
cells of these organs, when fixed in a solution of a 
salt of chromium, or chromic acid, become yellowish 
to brown in color. The medullary portion of the 
adrenals contains mostly chromaffin, or pheochrome 
cells. 

Each adrenal, of a yellowish color externally and 
dark brown internally, is in relation with the cephalic 
pole of the kidney of that side and lies in the epigas- 
tric region. Each weighs 6 to 7 grams and measures 
about 2 inches (4 to 5 centimeters) in height, H inches 
(3.75 centimeters) in width and J to^ inch (6 to 12 
millimeters) thickness. 

The right adrenal is triangular in outline and its 
base rests upon the cephalic extremity of the right 
kidney. Upon its ventral surface near the apex is 
seen a furrow, the hilus, from which the suprarenal 
vein emerges. This surface is moulded by the liver, 
laterally, and the inferior vena cava, medially. 

The left adrenal is .semilunar in outline and its 
base (concavity) rests upon the medial border and 
adjacent part of the cephalic extremity of the left 
kidney. The hilus is in the ventral surface, but near 
its caudal (inferior) end. 

The adrenals are retroperitoneal, though the peri- 
toneum may cover them to a variable extent. 

Histology. — The suprarenal capsule, or adrenal is 
surrounded by a capsule of white fibrous tissue that 
may contain some smooth muscle tissue. The 
capsule sends in trabecula- that have a different course 
in the different parts of the gland, thus causing the 
peculiar arrangement of the parenchyma. The tra- 
becuUe form a framework that supports the paren- 
chyma, vessels, and nerves. 



The parenchyma consists of two main parts, the 
cortex, usually yellowish in color, and the medulla 
that is of a dark red color. 

The cortex is the larger part of the organ and con- 
sists of three zones. The outermost is the zona glo- 
merulosa and the epithelial cells are arranged in oval 
or sphenoidal groups bj' anastomosis of the trabec- 
ul;c of the supportive tissue. This zone consists of 
two or three layers of these glomeruli (each of 
which is two to three cells wide) or in areas glomeruli 
may be absent. The second is the zona Jascicu- 
lata which consists of parallel rows of cells (two cells 
wide). This row formation is due to the parallel 
course of the trabecuUt which are here perpendicular 
to the surface. This is the widest zone. The third 
is the zona reticularis and here the cell cords anasto- 
mo.sc .ind produce a rcticuLir appearance due to the 





AWp 




['■ft'-i 



4095.— The Suprarenal Glands. Utudaich'; 
W. B. Saunders Co.) 



reticular arrangement of the trabecuhp of the frame- 
work and to the plexus of sinus-like veins. The 
cortical cells are polyhedral cells r2..')/j to 20^ in di- 
ameter. The cytoplasm is finely granular and con- 
tains small globules of lipoid material. This gives 
the yellow color to the cortex. In addition, secretion 
granules have been found. 

The medulla consist of anastomosing chains of 
cells with glomeruli here and there. The cells are 
large polyhedral and the cytoplasm finely granular. 
With special stains other granules (probably secre- 
tory) are found. When fixed in chromic acid or 
chromium salts these cells become brownish in color 
and are called chromaffin cells. Ganglion cells of 
the sympathetic system are also found in the medulla. 

Blood-vessels. — Each gland usually receives three 
arteries: (a) one from the aorta (suprarenal artery); 
(6) a branch from the inferior phrenic artery; and (o) 
one from the respective renal artery. The arteries 
enter the organ at the periphery, pierce the capsule 
and enter the trabecuhr. From these branches form 
a capillary plexus around the cells of the zona glome- 
rulosa, zona fasciculata, and empty into a venous 
plexus in the zona reticularis. Arterioles pass 
directly from the capsule to the medulla to form a 
plexus that is continuous with an extensive network 
of large anastomosing venous sinusoids. The endo- 
thelial cells of the latter are in close relation to the 
epithelial cells of the medulla, no doubt thereby 
facilitating the passage of the internal secretion of 
these cells into the sinusoids. The blood from the 
peripheral part of the cortex passes into the venous 
plexus of the zona reticularis and then into the medul- 
lary sinusoids. From the latter it passes to several 
veins near the center of the medulla and is then 
ultimately collected into a single vessel, the supra- 
renal vein, that leaves the organ at the hilus. The 

25 



Suprarrnal Glands, Anatamy 



REKERENCK HANDBOOK OK THE MEDICAL SCIENCES 



right vein is a tributary of the inferior vena cava; the 
left vein is a tributary of the loft renal vein. 

Lymphatic vessels form a plexus on the internal 
surface of the capsule and in the medulla and these 
two plexuses are connected by vessels that traverse 
the cortex. The lymph is carried by vessels from the 
capsule and fromthe medulla (by way of the hilum) 
to the lymph nodes near the organs. 

The it'enes are both sympathetic and cerebrospinal. 
They form the suprarenal plexuses that communicate 
witli the renal and celiac plexuses and the celiac 
ganglia. Numerous fibers are derived from the 
greater splanchnic, vagal, and phrenic nerves. The 
branches from the |)lexuses supply the vessels and 
ci)ithehum of the organ. 








Fio. 4G'.1G. — Section of Huit 
zonafasciculata; 4, zona reticularis; 5, cl 
lary vein. (From Radasch's Histology 



1 , Capsule ; 2, zona g 
mafBn cells of the medulla; 6, 
. Blakiaton's Son & Co.) 



Developments. — The suprarenal gland is of double 
origin, the cortex being derived from the mesothelium 
(mesoderm) and the medulla from the sympathetic 
ganglia (ectoderm). They are formed independently 
of each other and later unite. 

The cortical porlions appear in embryos of five to 
six millimeters as buds of mesothelial cells at the level 
of the cephalic third of the mesonephros. These buds 
grow into the mesenchyme at each side of the root of 
the dorsal mesentery. As these cells proliferate, each 
mass enlarges and becomes separated from the sur- 
rounding structures as an independent body. In 
fishes these never unite with their medullary divisions 
and constitute the interrenal organs. 

The vxedulla forms somewhat later from cells 
derived from the .sympathetic ganglia. These primi- 
tive ganglion cells give rise to two types of cells: 
(1) sympathetoblasts (future ganglion cells), (2) 
pheochromoblasts (future chromaffin cells). 

The pheochromoblnsts migrate to the cortical mass 
and lie m contact with it in ten to twelve millimeters 
embryos and penetrate it in cord-like mas.ses in embryos 
of twenty millimeters. These column-like groups are 
present in embryos up to ten centimeters. Some .sym- 
pathetoblasts are also carried in and these form the 
future ganglion cells of the medulla. In fishes each 
pheochrome mass forms the sujjrarenal organ. Dur- 
mg the union of cortex and medulla the suprarenal 
gland comes into clo.ser relationship with the perma- 
nent kidney. During the third and fourth months of 
intrauterine life each is larger than the corresponding 
kidney. At birth it is about one-third the size of the 
kidney. In the adult 1:28. The large size at birth 
is due to the h>-pertrophy of the inner part of the cor- 

26 



tex. This part is highly vascular and the cells possess 
no lipoid material. B3- the end of the first year this 
fetal cortex disappears and is partially replaced by the 
adult cortex which previously formed a thin marginal 
layer. The zona reticularis of the cortex is present in 
fifteen millimeters embryos, but the zona glomerulosa 
is not prominent until the second to the third year. 

Function. — The adrenals are ductless glands and 
give rise to an internal secretion, that is, a secretion 
that is taken up by the blood-vascular or lymph-vascu- 
lar system or both. From the gland an alkaloidal 
substance called epinephrin and also a crystallizable 
substance called adrenalin have been prepared. 
Whether either of these actually represents the true 
active principle is still in dispute. Under normal 
conditions the secretion maintains the 
normal blood pressure as well as the tonicity 
of the skeletal muscles. 

These substances produce contraction of 
the smooth muscle tissue of the various 
organs of the body. By their action upon 
the smooth muscle tis.sue of the blood- 
vessels, an increase in the blood pressure is 
produced. The administration of adrenalin 
is followed by an inhibition of contraction 
succeeded by a relaxation of the muscular 
walls of the other viscera, such as stomach, 
uterus, etc. Whether the extract acts upon 
the sympathetic nerves or the muscle tissue 
directly is still undetermined. Some believe 
that there is an intermediate "receptive 
substance" between the nerve endings and 
the muscle tissue, ultimately related to the 
muscle and upon this the extract acts. 

Stimulation of the splanchnic nerves 
causes an increase in blood pressure. An 
increase in secretion is also caused by emo- 
tional disturbances, as fright. In some 
animals emotional excitement is attended 
by glycosuria and h^-perglycemia. This 
may be due to the direct or indirect action, 
or through secretory nerves, upon the liver 
cells causing those cells to release the 
glycogen after converting it into sugar. 
Under this condition the presence of this readily 
available, energy-yielding material in the blood 
w-ould permit of sudden and increased muscular 
activity. H. E. Radasch. 



Suprarenal Glands, Pathology of. — Inasmuch 
as this subject has already been discussed to some 
extent in the article on A<ldisoti's Disease, only those 
conditions will be mentioned here which were not 
considered under that head. 

Anomalies and Malformations. — Total absence of 
the adrenals has been reported. Congenital absence 
and hypoplasia have been observed in cases of 
hemicephalus (hyi^oplasia), anencephalus, cyclopia, 
microcephalus, and in certain forms of malformations 
of the genito-urinary organs. According to Zander, 
the adrenal hypoplasia is associated only with defects 
of the frontal lobes. Aplasia of the medullary por- 
tion of the suprarenals has been seen in cases (jf 
chronic hydrocephalus, but the connection between 
these conditions is not clear. Hypoplasia of th(> 
chromaffinic tissue is sometimes associated with the 
thymicolymphatic status. Fusion into one organ, 
abnormality of shape and form, displacement, 
separation into several bodies, and hypertrophy have 
been described. As a rule, the malformations of (he 
suprarenals bear no relation to those of the kidneys, 
though in one case reported of horseshoe kidney there 
were four adrenals. Malformations of these organs 
appear to stand in a closer relationship with those of 
the sexual glands. Marchand has reported a case i>f 
marked hyperplasia of the suprarenals and of the 



REFERENCE HANDBOOK OF THE MEDICAL SICENCES suprarenal Glands, Pathology 



accessory suprarenal structures in the broad lisa- 
ment, in a case of rudimentary development of the 
ovaries and external hermaphrodism. 

Accessory Suprarenals (Adrenal Rests). — Small 
isolated portions of adrenal tissue, varying in size 
from a pinhead to a cherry, are of very frequent oc- 
currence in the immediate neighborhood of the main 
organ, Ij'ing in the periadrenal connective tissue, 
in the solar plexus, in or under the kidney capsule, 
in the kidney substance, or even in the liver. Small 
bodies consisting of tissue resembling that of the 
adrenal cortex are also found in the broad ligament, 
along the spermatic vessels, in the inguinal canal, 
on the spermatic cord, in the testis, and in the retro- 
peritoneal connective tissue. By a number of authors 
the adrenal tissue found in the last-named regions is 
regarded as analogous to the suprarenal organs of the 
lower vertebrates, the main adrenal organs of man 
representing the interrenal bodies of these animals. 
Marchand having been the first to ob.serve their 
presence in the broad ligament, they have been 
designated the "adren.als of Marchand." By other 
writers they are regarded as misplaced adrenal tissue 
referable to some disturbance of development or 
as independent formations arising from rudiments 
of the urogenital system. The chief pathological 
importance of these bodies is the possibilitj- of the 
development in them of the same form of new growths 
as arise in the adrenals themselves, or in the adrenal 
"rests" of the kidney, liver, etc. It is also possible 
that these accessory bodies may undergo a com- 
pensatory hypertroph}' in the case of destruction of 
the main organs in earlv life. Accessory adrenals or 
"adrenal rests" are of a yellowish color, and have a 
fatty shine. From their close resemblance to fat 
tissue they have frequently been mistaken for lipo- 
mata ("Grawitz tumors"). In the great majority of 
cases the microscopical structure resembles that of 
the fascicular or reticular zone of the adrenal cortex; 
and very rarely do these bodies contain cells resem- 
bling those of the medullary portion of the organ. 

Circulatory Disturbances. — Chronic passive con- 
gestion of the systemic veins gives rise to a -passive 
congestion of the adrenals, which in consequence are 
enlarged and of a deep brownish-red color. Adrenal 
hyperemia occurs in the infectious diseases, particu- 
larly in children. Diphtheria toxin produces a 
marked adrenal h>^^eremia. Passive congestion is 
usually the result of cardiac incompensation. Hemor- 
rhage into the adrenals may occur in congenital or 
acquired hemophilia, in pernicious anemia, in leucemia, 
in various infections (diphtheria, pneumonia, typhoid, 
septicemia, tetanus, etc.) after thrombosis of the 
veins, and as a result of trauma or of general passive 
congestion. Severe injuries, such as fracture of the 
spine, are frequently associated with hemorrhage into 
or about the adrenals. Hemorrhage into the supra- 
renals appears to be of frequent occurrence in the new- 
born. .■According to Mattel and Spencer, some degree 
of congestion of the suprarenals is always present in 
the new-born. In asphyxiated new-born the ad- 
renals may be completely infiltrated with blood or 
connected into blood cysts. Small hemorrhages may 
become organized; larger ones encapsulated, calcified, 
or in very rare cases replaced by true bone formation. 

Hemorrhagic infarction of the suprarenal due to 
thrombosis of the central vein has beqn reported as 
occurring in a child of eleven months. The etiology 
of the thrombus was not clear, but it was thought to 
be marantic in origin. A similar condition may 
follow thrombosis of the renal vein. Anemic in- 
farctions due to obstruction of the artery are very 
rare. 

Retrograde Changes. — Simple atrophy of the adre- 
nals occurs in old age and in cachectic conditions. .\ 
marked atrophy has been observed in cases of Addi- 
son's disease. The atrophic organs may be no larger 



than peas, or appear as thin translucent "ghosts" 
of the normal gland. Associated with the atrophy 
of old age there is frequently seen a marked pigmen- 
tation of the medulla. 

Necrosis of the adrenals occurs in tuberculosis, 
eclampsia, in certain infections and intoxications 
(diphtheria), in extreme passive congestion, and fol- 
lowing hemorrhage and thrombosis of the central vein. 
Focal necrosis has been observed in diphtheria and 
malaria. Inasmuch as the medulla of the adrenals 
very quickly undergoes a postmortem disintegration, 
such change occurring even within from half an hour 
to one hour after death, the presence of a soft 
brownish substance in a cyst-like cavity representing 
the medulla should not be mistaken for a pathological 
condition. The postmortem change may be recog- 
nized by the absence of hemorrhage or of changes in 
the cortex. The presence of cyst-like cavities formed 
by postmortem change gave rise to the designation 
"suprarenal capsule." 

Cloudy strelling of the cells of the adrenals occurs in 
severe general intoxications. 

Fat in the form of small droplets (anisotropic lipoids) 
is almost constantly present in the cortical cells 
of the adult adrenal, particularly in those of the 
fascicular zone. Large droplets are often present. 
Excessive fatty change has been described as occurring 
in marasmic infants and in cases of congenital and 
latent acciuired syphilis, and has also been regarded 
as a cause of Addison's disease. 

Amyloid change is of frequent occurrence in the 
adrenals in cases of general amyloidosis. The amy- 
loid is deposited in the walls of the blood-vessels 
and in the connective tissue. The parenchymatous 
cells become atrophic and may entirely disappear, 
the organ becoming larger, hard, waxy, and bluish 
gray in color. The cortex usually shows the greatest 
change, but the medulla is not infrequentlj' affected 
alone or coincidently. Amyloid change of the adrenals 
has also been regarded as a cau.se of Addison's disease. 

Calcification of the adrenals may follow caseous 
necrosis or hemorrhage, and is not infrequently present 
without any signs of other pathological changes, a 
metaplasia of the calcareous deposit into true bone 
may occur. 

Pigmentation of the cells of the medulla is increased 
in old age and in conditions of excessive blood de- 
struction. 

Cysts. — The postmortal degeneration of the 
medulla produces a false cyst of the organ. Other 
cysts arise as the result of hemorrhage. True 
lymphangiomatous cysts have been observed. Epi- 
tlielial cysts are extremely rare. 

LvFL.uiMATioN. — Simple inflammation of the adre- 
nals is very rare. Aletastatic abscesses occur in 
pyemia and may lead to total destruction of the organ; 
they may rupture into the intestine or into the re- 
troperitoneal connective tissue. Fibrosis of the 
adrenals due to chronic interstitial inflammation has 
been reported, but the nature of these cases is obscure. 
Such changes have also been reported as occurring in 
.\ddison's disease. Latent syphilis is probably the 
chief etiological factor. 

Tuberculosis. — Miliarj- tubercles may be found 
in the adrenals, but tuberculosis of these organs is 
usually of the fibrocaseous type. The glands in the 
latter condition become enlarged, hard, and often 
nodular. The capsule is thickened, the parenchyma 
either wholly or in part replaced by a firm, dry, cheesy, 
yellowish, or soft pus-like material. About the 
capsule there may be present a large amount of scar 
tissue involving " the semilunar ganglia. Tubercle 
bacilli are found in the caseous areas. Calcification 
or liquefaction may follow the caseation. In many 
cases only one organ is affected. The condition is 
rarely primary, but is in the great majority of cases 

27 



Suprarenal (ilands. Palholag)' 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



sei'oiulary to :i chronic pulmonary tuberculosis. In 
eighty-nine per cent, of cases it is present on both 
sides." When primary it may form tlie starting-point 
for a tuberculosis of the peritoneum. ConRcnital tuber- 
culosis of the adrenals has been ob.served in an infant 
twelve days old. (See Addison's Disease.) 

Syphilis. — Gunimata have been found in the adre- 
nals, and in both congenital and ac(|uired syphilis 
thickening of the blood-vessels may occur. Total 
fatty degeneration has also been described as occiirring 
in cases of congenital syphilis. In the majority of 
eases of congenital syphilis spirochetes occur in 
great numbers in the adrenals without causing ap- 
parent changes. In old latent syphilis the adrenals 
frequently show thickenings of the capsule and small 
collect ioiis of mononuclear and plasma cells, par- 
ticularly in the cortical zone bordering upon the 
medulla. The stroma may be increased. 

AcTiNOMYCttsis of the adrenals has been reported as 
extending from actinomycotic processes in the liver. 

Rabies. — Negri bodies have been found in the 
ganglion cells of the medullary substance. 

PaooRESSiVE Chaxges. — Hypertrophy and hyper- 
plasia of adrenal tissue may occur in young individuals 
after loss of the main organ or organs. In the latter 
ease the adrenals of Alarchand or other accessory 
adrenal tissue may undergo a compensatory hy- 
pertrophy. The diffuse hyperplasias are very rare, 
but localized nodular hyperplasias are frequent. 
The small local hypertrophic nodules of the cortex 
pass without sharp transition into the so-called 
adenoma of the cortex and the accessory adrenals. 
The regenerative capacity of the adrenal tissue is 
very slight. In experimental hypertrophy after 
removal of one organ an increased development of 
parasympathetic elements is said to occur. Increase 
of the chromaflinic tissue has been observed in 
pregnancy, nephritis, atherosclerosis, cardiac hyper- 
trophy, etc. Experimental hyperplasia of the med- 
ulla has also been observed in nephrectomy. Trans- 
plantation of adrenal tissue into the kidneys has 
been successful. 

Tumors. — The most common form of tumor is 
that arising from adrenal rests (see Hypernephroma). 
these growths may reach a very large size, and 
occasionally present the appearance of a large cyst 
filled with a brownish pultaceous material produced 
by the extensive fatty degeneration characteristic of 
these growths. The smaller growths appear as 
yellowish nodules resembling fat tissue because of 
their great richness in lipoid droplets {" tumors of 
Grawitz"). The microscopical picture is usually that 
of the fascicular zone of the cortex, but growths con- 
sisting of medullary tissue have al.so been described. 
Though frec|Uently benign except for size, the hyi)er- 
nephromas of the adrenals may through continued 
atypical growth take on the characteristics of a car- 
cinoma. It is probable that 'the majority of the 
malignant tumors arising primarily in the adrenals, 
which have been reported as carcinomata, in reality 
belonged to the hypernephromata, though it is also 
possible that tumors of the type of carcinoma may be 
primary in this organ. The term adenoma or malig- 
nant adenoma is frequently applied to these growths 
{struma suprarenalis); at present they are classed 
with the hyiierncphromata. The malignant hyper- 
nephroid tumors of the adrenals are in general charac- 
terized by their abundant content of fat and glycogen, 
and their tendency to form pulmonary and bone 
metastases. 

Sarcoma. — Melanotic and non-pigmented sarcomata 
have been reported as primary in tiie adrenals. Lym- 
phosarcoma is of rare occurrence. There exist in the 
literature numerous accounts of sarcoma of the 
adrenal, but it is very probable that these tumors 

28 



belonged to the hypernephromata and not to the 
true sarcomata. This is especially true of the cases 
reported as "malignant tumor," "adenosarcoma," 
"alveolar sarcoma," "carcinoma," etc. Through 
the occurrence of hemorrhages the growths may 
become very large, and occasionally break into the 
veins and .set up metastases. The latter are found 
chietiv in "ic lungs. 

Gliomnta and iicuromnta of the adrenals have been 
described, but the true nature of the cases is uncertain. 
They arise from the medulla or from the sympathetic 
system. 

Connective-tissue growths are very rare. Cystic 
lymphangioinata, lipoma, fibromyoma, and tumors 
containing bone-marrow tissue, ganglion cells and 
nerve hbers have been very rarely observed. Gangli- 
onic iibromyoangioma has also been described. 

Secondary tumors (sarcoma and carcinoma) are of 
not infrequent occurrence. Metastasis takes place 
usually through the lymphatics. Secondary car- 
cinoma may be associated with Addison's disease. 

Parasites. — In very rare cases echinococrus has 
been found in the adrenals. 

.\i.DREi) .Scott Warthin. 

Suprarenal Glands, Physiology of.— See Secretion, 
PhysU)logy of. 

Surgery, History of. — The history of surgery- 
studied comprehensively must include that of medi- 
cine and general civilization, but such a history, how- 
ever valuable as a contribution to historical literature, 
cannot be comprised within the limits of this article. 
Nor from the viewpoint of the ordinary surgical 
student would it sujjply in available and impressive 
form those latent and often unrecognized forces which 
in the course of centuries evolved surgery from a 
simple rude art to a practical science. 

The development of an art is always characterized 
by a succession of related events each of which marks 
another step of progress. These events may be of 
slight apparent importance and yet, as Sir James 
Fagot remarks, "closcl.y studied, they are all links in 
an endless chain of events leading to a higher devel- 
opment, as we witness in the evolution of the embryo." 
But in this logical chain of events there often occurs 
one of such importance that it creates an epoch by the 
radical changes which it affects. Baas ("History of 
Medicine") remarks of epochs, "If we look upon the 
history of medicine as a department entirely separable 
from the general history of civilization, it is justifiable 
to fix upon special epochs and to regard particular 
services of representative persons within these epochs 
as special landmarks." 

As these epochal events are great beacon lights 
which illumine the pathway of the pioneer the suc- 
ceeding history is designed to trace the progress of 
surgery from prehistoric times by an exposition of 
these events. Though this course is necessary owing 
to the limitations given the author, it has its advan- 
tage in this that the student more readily recognizes 
the scientific spirit which after centuries of contention 
with the hostile forces of ignorance, superstition and 
empiricism has given to humanity one of its most- 
powerful and effective agencies in the rehef of suffering 
from hitherto incurable diseases. Again, the dis- 
cussion of the peculiarities of these epochal events 
necessarily includes an historical notice of the great 
masters of surgery who, endowed with a genius for, 
analytical and sj'nthetical research and a deeper in- 
sight into the operation of physical forces, have- 
coordinated the accumulated facts and experiences of 
the past into a simple and more effective code of pro- 
cedure and thus have created an epoch. 

Our sources of knowledge of surgery in the 
earhest periods are very imperfect as it is deriv.il 
from hieroglyphics on tombs and monuments ami 
cursive writings on papyrus. Max Miiller alludes to 






REFERENCE HANDBOOK OF THE MEDIC.VL SCIENCES 



Surgery, History of 



pictures engraved on the door-posts of a tomb near 
Memphis representing surgical operations 2500 b.c. 
These are believed to be the earliest pictures of this 
kind known. The most important of the cursive 
writings are those of Evers of the date of 1550 B.C. 

The recent revelations of prehistoric people explain 
the advanced stage of progress in the arts of civiliza- 
tion of the old historic nations as the Egyptians 
and Hindus. ' It has been a surprise that in the earliest 
recorded events of their history they were practising 
arts belonging to a higher civilization than they had 
attained. It now appears that they may have de- 
rived their knowledge from a much older people who 
had attained a higli grade of physical, mental and 
industrial development. Such people are now known 
to have existed in the remotest ages in the central 
portion of western .Asia. 

Prof. Osborn in his recent work (" Men of the Stone 
Age. Their Environment, Life and Art") throws a new 
light on the antiquity and civilization of primitive 
man. He concludes that the 125,000 years during 
which men used implements of chipped stone repre- 
sent a complete cycle of human development; that the 
sudden appearance in Europe at least 25,000 years ago 
of a human race with a high order of brain power and 
ability was not a leap forward but the effect of a long 
process of evolution elsewhere. During this age the 
rudiments of all the economic powers of man were 
developed, the guidance of the hand by the mind, 
manifested in his creative industry, his inventive 
faculty, his sense of form, of proportion, of symmetn,-, 
the appreciation of beauty of animal form and the 
beauty of line, color, and form in modeling and 
sculpture. 

The Knife and the C.^rTERY (Prehistoric). — The 
first epoch in surgery occurred in prehistoric time but 
the date we do not and cannot know, and its origin 
we can only conjecture from the implements eniplo3'ed 
by primitive people and which have come down to 
us in their original condition. It is assumed by his- 
torical writers that the first treatment of disease was 
by surgical methods. Baas says. ''The first medical 
services were of a surgical character, and these had 
attained a certain degree of perfection at a period 
when scarcely any traces of internal medicine were to 
be found." 

AVe may safely conclude that external affections as 
ulcers, wounds, growths, abscesses, appealed to the 
senses of primitive man for relief by any means at his 
command. Evidently the first recognized want of the 
prehistoric surgeon was a penetrating and cutting 
instrument. This instrument he found ready at 
hand in the stone knife in familiar domestic use. 

Garrisonsays ("History of Medicine") "The earliest 
surgical instrument was in all probability not the 
specialized leaf-shaped flint or 'celt' — but rather some 
fragment unusually sharpened as to edge and point 
by accidental flaking. . . . By means of these sharp- 
ened flints, or of fishes teeth, blood was let, abscesses 
emptied, tissues scarified, skulls trephined, and, at a 
later period, ritual operations like circumcision were 
performed . . . with the primitive celts themselves." 
He adds the interesting suggestion that there is such a 
solidarity of folklore "that folk ways of early medicine, 
whether .\ccadian or Scandinavian, Slavic or Celtic, 
Roman or Polynesian, have been the same." Hence 
we may conclude that the stone knife was the first 
surgical instrument. There is one recorded instance 
of its being used in a surgical operation. In Exodus 
(iv, 25) it is written, "Then Zipporah took a sharp 
stone and cut off the foreskin of her son." 

The necessary complication of a cutting operation 
was a more or less free flow of blood which must be 
promptly and permanently arrested. We can only 
assume that pressure directly on the vessel in the 
wound would be the first impulse of the operator, but 
that means would be only temporary. From the 



early application of heat to wounds, as hot oil, we in- 
fer that its effect in controlling hemorrhage must have 
attracted attention, and led to the direct application 
of the heated stone and hence the first appearance of 
the actual cautery, an instrument which was to have a 
large place in surgical operations. This appears from 
an ancient apothegm of the Hindus; -The fire cures 
diseases which cannot be cured by physic, the knife 
and drugs." In fact the cautery as tlien constituted 
did supersede the knife with many surgeons owing to 
its twofold qualities of cutting and at the same time 
arresting hemorrhage. 

During the succeeding nameless centuries to the 
-second epoch it is impossible to trace the progress of 
surgerj- with any exact continuity of events in the 
absence of reliable historical data. " We can onlv state 
in general terms the few facts that are of record. 

Egypt is regarded as one of the oldest historical 
countries and is believed to have derived manj- of the 
more important elements of its civilization "from a 
highly cultivated antecedent people. .\s early as 1552 
n.r. there were independent practising physicians, 
besides the Temple priests. Heroditus states that the 
art of medicine was divided amoni; them: "Each 




1 



Fig. 4iiH7. — Operative Surgery in Egypt. Fn.m a carving on a 
tomb. 2500 B. C. 

physician applies himself to one disease only and not 
more. All places abound in physicians." Baas says 
of the Egyptians: "In surgery, and especially in 
operative surgery, the physicians of the warlike 
Pharaohs accomplished considerable, and obtained 
results fully capable of refuting the denials of this fact 
dictated by the self-sufficient vanity of the old Greek 
writers. They bandaged suppurating ulcers, prac- 
tised venesection, and cupped by means of bones sawed 
off near the point. They performed circumcision 
. . . using apparently knives of flint and they also 
practised castration by crushing or pounding the 
testicles and more rarely with the knife. They prac- 
tised lithotomy with a dexterity preserved as a secret^ 
and, indeed, performed amputations. In ophthalmic 
surgery they were especially skilful." 

Indian or Hindu medicine about 1300-500 b.c. was 
the most comprehensive known throughout all antiq- 
uity, except the Greek. The Indians were familiar 
with a great variety of surgical diseases as ulcers, ab- 
scesses, hernia, fractures, dislocat ions, orchitis, epididy- 
mitis, fistula in ano, tumors in general. To success- 
fullv meet the varying conditions that would be found 
in operating uponsuch eases a number of instruments 
would be required in addition to the knife. The 
Indian surgeon showed a genius for devising the 
requisite instruments for such emergencies. We find 
in his collection of instruments forceps, saws, needles, 
specula, niox.as, enema svringes, the actual cautery, 
and other apparatus. Baas says : •' Operative surgery 

29 



Surgorj, History of 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



attained such a position auioiiR the Indians that thoy 
did not slirink from the greatest and most difficult 
operations." 

Garrison says: "The Hindus apparently knew 
every important operative procedure except the use 
of the lipature. They amputated limbs, checkins 
hemorrhaKc bv cauterization, boiling oil or pressure. 
Thev treated fractures and di.slocatioiis by a .special 
splint made of withes of bamboo which was subse- 
<iuentlv adopted in the Hritish .Vrniy as the 'patent 
rattancanc splint.' They performed lithotomy (with- 
out the stalT), Cesarean section, excision of tumors 
and the removal of omental hernia through the scro- 
tum. Their mode of extracting cataract has survived 
to the present day and they were especially strong in 
skin-grafting and other phases of plastic surgery." 

He also states that: "The Hindus were especi.ally 
clever in their method of teaching surgery. Realizing 
the importance of rapid, dexterous inci.^ion in oi)ora- 
tions without anesllusia, they had the student practise 
upon plants. The hollow stalks of water lilies or the 
veins of large leaves were punctured or lanced as well 
ns the blood-vessels of dead animals. Gourds, cu- 
cumbers and other soft fruits, or leather bags filled 
with water were tapped or incised in lieu of hydrocele 
or any other disorder of a hollow cavity. Flexible 
models were used for bandaging, and amputations 
and the plastic operations were practised upon dead 
animals. 

Egyptian and Hindu medicine spread among the 
neighboring nations but in none did it excel the stand- 
ard attained by tho.se countries. No great mind 
appeared during the centuries before the second epoch 
which was capable of giving a new impetus to the 
development of surgery. Garri-son says: "Wiat wc 
owe to oriental medicine, the H.abylonians specialized 
in the matter of medical fees, the Jews origin.ated 
medical jurisprudence and public Iiygiene and or- 
dained a weekly day of rest, and the Hindus demon- 
strated th.at skill in operative surgery which has 
been a permanent possession of the Aryan race ever 
since." 

Thus, in the vast prehistoric centuries we fix without 
date the simple beginnings among primitive people of 
the first epoch of surgeTy as an art. The outcome of 
that epoch was Itie remarkable progress which its 
practisers made in the increase of the number, variety 
and adaptation of instriiments to the emergencies of 
practice. It was jjractically an epoch of the invention 
of in.struments. It necessarily followed that by 
these inventions the range of operations was extended 
so that at the commencement of the second epoch the 
number of ditTerent ojierations performed was sur- 
prisingly l.irge. 

The genius of the oriental mind tended to the per- 
fection of handicrafts or objective works, and but 
slightly to the subjective, which require for their 
successful prosecution inductive methods of .study. 
Hence an art like operative surgery which must de- 
pend for its success upon accuracy of diagnosis could 
not attain to precision except when its acts were 
guided by principles established by scientific methods 
of research. Evidently there was not that scientific 
spirit in those early nations which by proper analy- 
tical and synthetical processes would utilize facts 
and experience in establishing correct principles of 
practice. 

lNDnrTi\-E Metimds OF RESEABrn (Hippocrates 400- 
370 B.C.). — The time had come when, if surgery was 
to develop beyond a mere handicraft, it must be culti- 
vated by a receptive people whose teachers must be 
adapted by temperament, genius, and experience for 
inquiry and research into those basic principles which 
underlie and govern the development of the disea.scs 
which as an art the practisers were now (|ualified to 
relieve or cure. The field to be cultivated mu.st be 
charted and a code of procedure established based on 

30 



the immutable princii)les of science. Such a people 
with its pioneer teacher was already equipped and 
awaiting the summons to the task. 

Civilization in its progress westward, unlike its 
spread among the decaying nations of the East, was 
constantly meeting more and more intellectual, re- 
ceptive and aggressive peoples. At_ that period 
Greece excelled all preceding n.ations in its intellectual 
adaptation to lay the foundations of the art of surgery 
on a scientific basis. Uaas says: ''The Greeks in- 
corporated info their own culture original portions of 
the primitive civilizations; tliey raised these foreign 
elements at once to an extraordinary perfection and 
development; whatever they touched iiitellectu:dly. 
or incorporated frcun without, they purified, cleNateil 
and refined; the simple knowledge of these |)riinitivi> 
peoples they developed and elevated info the lilx-rnl 
sciences; the stereotyped, mechanical forms of the 
former became, tinder their hands, a genuine art; the 
Greek mind strove always for the profound and entire 
and was not contented with knowledge of facts alone 
in medicine, but ever sought the inmost essence, aim 
and object, a knowledge of disease in itself rathet than 
of individual species of disease and their peculiar 
phenomena." 

Egyptian medicine was introduced into Greece, 
according to its mj-thology, by ^sculapius (1250 
B.C.). He is reputed to have come from Memphis, in 
Egypt, and to have brought medicine from that 
country. After his death he was exalted to the posi- 
tion of the God of Medicine and a special cultus was 
introduced by his priests. The places devoted to his 
cultus were called .■Esclepieia to which the sick resorted 
for treatment. These jEsclepieia became the re- 
positories of the records (tablets) of the diseases of the 
sick who visited them for treatment. This practice 
led to the creation of schools of medicine in connection 
with the iEsdepieia. 

The earliest mention of surgeons in Greece was by 
Homer who speaks of the two sons of .(Esculapius — 
Machon and Podalirius — as actively engaged in the 
Homeric wars. Machon was summoned to remove an 
arrow which was driven through the belt of Menelaus, 
King of Sparta; he extracted the arrow from the well- 
fitted belt, but while it was being extracted the sharp 
barbs were broken; then he loosed the variegated 
belt and the girdle beneath and the plated belt which 
brass-workers had forged; when he perceived the 
wound where the bitter shaft had fallen, having 
sucked out the blood he skillfully sprinkled on it 
soothing remedies (Garrison). 

From the same author we quote: "Eurypylus 
wounded with an .arrow in the thigh calls upon Patro- 
clus to remove it. Patroclus laying him at length, 
cut out with a knife the bitter, .sh.arp arrow from the 
thigh, and washed the black blood from it with warm 
water. Then he applied a bitter, pain assuaging root, 
rut^bing it between his hands, which checked all his 
p.ains; the wound indeed dried up, the bleeding having 
ceased." 

That surgeons were attached to divisions of the 
Greek army is evident from the statement of Xeno- 
phon that ten surgeons were assigned to his army of 
10,000. Homer describes more than forty wounds in 
different parts of the body and with such accuracy of 
details as to suggest that they came within his personal 
knowledge. War was regarded as the proper school 
for learning the art of surgery while the practice of 
medicine was learned at the temple-schools of the 
.Esclepieia. 

Though these schools were active agents in promot- 
ing .a knowledge of medicine it was not until the genius 
of Hippocrates was applied to what w^as regarded as a 
department of philosophy that medicine and surgerv 
became .sciences. He w.as peculiarly adapted to apply 
to the vast accumulation of hitherto unrelated facts 
and experiences of the past centuries the inductive 
method of arriving at scientific conclusions and 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



establish on them as a basis a logical and rational 
sj'stem of practice. 

The life of Hippocrates was cast in the golden period 
of Greek art, literature, and philosophy. He was a 
contemporary of Socrates, Plato and Aristotle; of 
Heroditus and Thucydides; of Sophocles and Euripi- 
des; of Pericles and Demosthenes. He was the son of 
a physician and had the education of the schools of 
the period; he practised his profession during a wide- 
spread epidemic and became famous; he traveled 
extensively and was a careful observer; he was a 
teacher of medicine and gave to the school at Cos its 
great reputation. His writings exhibit a mind trained 
to close observation; to the judicious discrimination 
between the true and the false; to exact expression; 
and, above all, to a synthetic or orderly arrangement 
of subjects and details. 

Billings saj's ("History of Surgerj-"): "The surgi- 
cal part of the Hippocratic Collection is much more in 
accordance with modern views than the medical part; 
but there are certain characteristics of all the books 
generally considered to have been written by Hippo- 
crates himself, which are worthy of special attention 
in connection with the high repute in which they have 
been held by medical men for over 2,000 years. In 
the first place, it is evident that one of his special aims 
was to be entirely honest and truthful in his state- 
ments. He reports no marvelous cures, no speci- 
mens of extraordinary success in diagnosis where others 
had failed; fatal cases are given as well as recoveries, 
and there are no hints that the former were not seen 
in time nor that they had been improperly treated by 
others." 

The acknowledged works of Hippocrates include the 
treatises on "Injuries of the Head;" "Fractures;" 
"Articulations;" "Bones, Their Injuries and Di.s- 
placemcnts;" "Wounds and Ulcers;" "Fistula;" 
"Hemorrhoides;" the "latrium" or "Surgery." 

The books on articulations, dislocations and frac- 
tures, are .systematic treatises and though based on an 
imperfect knowledge of anatomy show a careful dis- 
crimination of symptoms and the results of large 
experience in the treatment of the latter accidents. 
Diseases of the joints are judiciously treated and 
the use of massage recommended. Fractures are so 
intelligently discussed as to be regarded by high 
authority as quite in accord with modern ideas and 
practice. The author suggests a novel method of 
equalizing the length of limbs, when one has been 
shortened, viz., by fracturing the uninjured hmb and 
reducing it to the length of the other. 

Allbutt says ("Relations of Medicine and Surgery") : 
"In respect of fractures and luxations of the forearm, 
Petrequin pronounced Hippocrates more complete 
than Boyer; in respect of congenital luxations richer 
than Dupuytren. Malgaigne again admires his com- 
parison of the effects of unreduced luxations on the 
bones, muscles, and functions of the limb in adults, in 
young children, and before birth, as a wonderful piece 
of clinics. In Littre's judgment, the work of Hippo- 
crates on the joints is a work for all time." 

Dislocations form an interesting feature of the Hip- 
pocratic surgical works as they seem to have been of 
common occurrence, due it has been suggested 
(Adams) to the liability to that accident of wrestlers 
at the public games. Of di.slocations at the shoulder 
it is stated (Baas) that: "The head of the humerus is 
often luxated, but not upward, in consequence of the 
acromian; nor backward, by reason of the scapula; nor 
forward, in consequence of the biceps muscle, but 
rarely inward or outward, yet frequently and chiefly 
downward." 

Of dislocations at the knee- and elbow-joints it is 
alleged (Billings): "Luxations and subluxations at the 
knee .are much milder accidents than subluxations and 
luxations at the elbow; for the knee-joint in propor- 
tion to its size, is more compact than that of the arm 
and has a more even conformation, and is rounded, 



Surgery, Historj- of 



while the jomt of the arm is large and has manv cavi- 
ties. . . . Dislocations at the elbow are more trouble- 
some than those at the knee, and, owing to the inflam- 
mation which comes on and the configuration of the 
joint, are more difficult to reduce if the bones are not 
immediately replaced. The bones at the elbow are 
less subject to dislocation than tho.se of the knee, but 
are more difficult to reduce and keep in their position, 
and are more apt to become inflamed and ankylosed.' 
. . . Owing to their configuration, the bones" of the 
knee are indeed frequently dislocated, but thev arc 
easily reduced for no great inflammation follows nor 
any constriction of the joint. . . . They are dis- 
placed for the most part to the inside, sometimes to the 
outside and occasionally into the ham. The reduc- 
tion in all these cases isnot difficult, but in the dislo- 
cations inward and outward the patient should be 
placed on a low seat, and the thigh should be elevated 
but not much. Moderate extension for the most part 
sufficeth, extension being made at the leg and counter- 
extension at the thigh." 

It appears that Hiiipocrates makes no mention of 
amputations through living parts but alludes to the 
successful separation of a limb by gangrene after the 
crushing of the vessels or the application of a bandage 
too tight in the treatment of fracture. He recognized 
the importance of the union of wounds by first inten- 
tion and advocated cleanliness in dressing wounds to 
secure that result. Wounds of the head are to be 
treated without the application of liquors, cataplasms 
or tents, unless they are on the forehead or the part 
without hair, or about the eyebrow and ej'e. The 
wound rnay be enlarged for examination of the bone 
when it is suspected to be injured and these incisions 
may be practised with impunity except on the temple 
and parts above it where there is a vein crossing; for 
convulsions seize on a person who has been thus 
treated ; if the incision be on the left temple the convul- 
sions seize on the right side, if on the right temple the 
convulsions take place on the left side — showing a 
knowledge of the decussation of the cerebr.al nerves. 
Of the treatment it is stated that those injuries requir- 
ing trepanning are contusions, whether the bone is 
bare or not, and fi.ssure whether apparent or not; 
exceptions to trepanning are bones depressed, "and 
those which are most pressed and broken require 
trepanning the least." 

Hippocratic literature covered nearly the entire 
known field of medicine and surgen,' and, as Garrison 
remarks, "voiced the spirit of an entire epoch." 
While the authors of this literature are believed to 
have been numerous, it is generally admitted that they 
belonged to the Hippocratic School. .\s a teacher, 
author, and practiser Hippocrates exerted a controlling 
influence, not only upon the medical thought of his 
time, but of all future time. "In a word he w;is the 
great creator of scientific medicine and of artistic 
practice" (Baas). The same author adds: "The 
undying importance of Hippocrates in medicine rests 
first of all, not so much upon his enrichment of science 
with new material (though this honor is his unques- 
tioned due), as upon the creation of a (lay-) medicine 
and art; upon the method and really great principles 
which he introduced for all lime into science and espe- 
cially into practice." From Celsus' writings we leam 
that during the first three centuries of the Hippocratic 
Epoch the practice of surgery was characterized by 
gre.iter skill due to more scientific methods. 

The medical schools of Greece were active agencies 
in promoting the study of medicine which was re- 
garded as a branch of Greek philosophy prior to the 
Hippocratic Epoch. There were between fifty and 
si.xty temples of .Esculapius in Greater Greece where 
instruction was given in medicine and surgery as 
early as 600 B.C. Of these schools two, viz., that of 
Cnidos and that of Cos became the most famous 
in the annals of Greek medicine. Students were 
attracted to these Schools from other countries and 

31 



SurKPry, lllstor) of 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



became the means of diffusing a knowledge of Creek 
surgery among existing nationalities. The izistruct- 
c.rs in these schools were the most eminent men of 
their time in the science and art of surgery. It was m 
the School of Cos that Hippocrates developed his new 
theories based on the inductive method of analyzing 
facts and formulating conclusions. Both schools had 
a literature which was held in great repute for centu- 
ries. Tlie School of Cnidos published its"Cnidiaii 
Sentences" and that at Cos its '■ Pra-notiones Coaex." 

In Greater Greece, Aristotle (3S4-:522 B.C.), a 
pupil of Plato, supplied a most important elenicnt in 
the linal perfection of the art of surgery by his pro- 
motion of the study of anatomy. While his own 
contributions were chiefly in the field of comparative 
anatomy and cmbrvologv, it was through the influence 
of his pupils that the schools of Alexandria in Egypt, 
were established, whidi became famous as centers of 
instruction in anatomy. 

The following surgeons practised in the early 
Hippocratic Era: 

Cliri/sippus, of Cnidos (340 B.C.), arrested hemor- 
rhage by applying a ligature tightly to the limb above 
the bleeding "point. Praxagoras, of Cos (355 B.C.), 
practised taxis in every possible way in strangulated 
hernia, performed herniotomy, amputated the uvula, 
recommended laparotomy in obstruction of the intes- 
tine and removal of the cause of obstruction. Hero-, 
philus, of Chalcedon (355-280 B.C.), a pupil of 
Praxagoras of Cos, was a distinguished teacher of 
anatomy in the School of Alexandria; discovered the 
calamus scriptorius, the torcular Herophili, the 
venous sinuses, the chyliferous and lymphatic vessels, 
the livoid bone, the duodenum, the prostate gland, and 
described the anatomy of the eye. Erasistralus, of 
lulus (200 B.C.), was a pupil of Chrysippus, of Cnidos, 
and became a colleague of Hcrophilus in the School of 
.Alexandria. He described accurately the gross anat- 
omy of the brain and regarded the convolutions of the 
cerebrum and cerebellum as the seat of thought; 
also the trachea to which he gave its name, the vena 
cava valve. He explained the development of the 
embrvo by new formation — epigenesis. Asdepiades, 
of Bythinia (124 B.C.), studied in Alexandria, prac- 
tised at .\thens and Rome, was a solidist, and founded 
the School of Methodism, discarded anatomy, relied 
on medication and not on nature and in this as in 
many other opinions was an avowed opponent of 
Hippocrates. He is credited with performing the 
first recorded tracheotomy which he practised for the 
relief of angina. He also gave the name "phrenitis" 
to certain mental diseases. He scarified the ankles in 
dropsy, performed paracentesis with a smalt wound, 
recognized spontaneous luxation at the hip-joint, 
gained great popularity with the people by the alleged 
revival of a dead man. While living at Rome ho 
taught rhetoric, became a friend of Cicero and 
Crassus and by his cleverness accomplished much in 
allaying the prejudices of the Romans against Greek 
physicians. 

The teachings of Hippocrates awakened in the 
susceptible Greek mind a speculative rather than a 
practical tendency with the result that most of the 
medical and surgical writers of the next centuries 
devoted themselves to the advocacy and practice of 
theories. This incessant theorizing of teachers and 
writers naturally led to the division of the profession 
into schools of practice. The basis of each school was 
the assumed relations of the solid, liquid, antl gas 
constituents of the body to disease and the practice of 
each sect was governed by the adherence of the indi- 
vidual practiser to solidism, humoralism, or pneu- 
matism. In this "welter" of the o.-ics, as Garrison 
characterizes them, surgery as a science, made little 
substantial progress. 

It had the elements of a philosophy and was taught 
in its schools with great enthusiasm. Pupils were 
attracted to these schools in large numbers and on the 

32 



completion of their education they located in practice 
in home and foreign cities. As a result Greek medi- 
cine and surgery, which w^ere then taught as branches 
of a single subject, spread widely among surrounding 
nations, both West and East. 

In the West wc first learn of the practical extension 
of Greek surgery to the Roman Empire (219 b.c). 
In that year Archagathus, a native of Peloponnesus, 
Cireece, "located in Rome. iVlthough he secured 
citizenship he was subsequently banished from the 
city as a "carnifex" (butcher) because he used the 
knife and cautery so freely. The incident illustrates 
the prejudice of the Romans against Greek culture. 
Pliny savs: "The dignity of the Roman does not 
permit him to make a profession of medicine, and the 
few Romans who begin to study it are venal renegades 
to the Greeks." Again he states that: "The Roman 
people for more than 600 years were not, in- 
deed, without medical art, but thej' were without 
physicians." 

Baas comments on this statement as follows: " This 
art consisted merely in prayers, dietetic measures, 
prescriptions from the Sybelline books, charms, etc. 
That the Romans cherished much grosser supersti- 
tions than the Greeks is well known. With rude 
simplicity they elevated into divinities those evils 
w'hich especially harrassed them, in order probably 
to rid themselves of them by such promotion, and 
then worshiijped these deities with fervor." He adds: 
"In this early period physicians formed a class dis- 
pised by the better order of Romans, for medicine 
down to the time of Caeser and even later, was con- 
sidered an occupation unworthy of one of the CJuir- 
ities, in fact as dishonorable." Surgery was believed 
to be adapted to the functions of a barber, or bather, 
or other person engaged in the care of the sick. En- 
couraged by such a state of public opinion the barbers 
assumed the duties of cupping, venesection, applying 
leeches and minor operations. 

However slight may have been the advance of 
surgery among the Romans as a people, it is neverthe- 
less true that by their tolerance of Greek surgeons 
they w-ere instrumental in protecting and conserving 
the scientific spirit which has characterized its devel- 
opment at all periods. Garrison says: "Under the 
Romans, surgery . . . attained to a degree of per- 
fection which it was not to reach again before the 
time of Ambroise Par6. Surgical instrumentation, 
in particular, was highly specialized. Over 200 
different surgical instruments were found at Pompeii. 
Herniotomy and plastic surgery were known, as well 
as the operations for cataract, version, and Cesarean 
section. 

Christianity a New Element in Civilization. — 
The teachings of the Founder of Christianity created 
an epoch in human history. His doctrines established 
new ideals of life which profoundly changed the char- 
acter of every individual who received and practised 
them. Human life now under all conditions became 
.sacred and appealed for protection to the highest 
moral obligation of which man is conscious. 

Hitherto, the care and cure of the sick, the protec- 
tion and support of the helpless young and feeble 
aged were undertaken from the common impulse of 
luman sympathy or the requirements of the State. 
The teacliings and the life of the Christ exalted the.se 
ministrations to the realm and sacredness of religious 
oliligations. It was no longer a duty to save human 
life in the economic interests of the State, but in an 
exalted recognition of the brotherhood of man. A 
new_ and holy motive was henceforth to inspire 
Christian cottimunities in their social relations and 
humane efforts. Hospitals were erected for the sick 
and asylums were created for the dependent classes. 
The influence of these works of charity upon the 
people was thus expres.sed by the Emperor, Julien, 
who wrote Oribasiiis, the most distinguished surgeon 



REFERENCE HANDBOOK OF THE MEDIC.Al, SCIENCES 



Surgery, History of 



of the period, that "these Christians had established 
everywhere hospitals in which not only their own 
people, but also those who w'ere not Christians were 
received and cared for . . . that it would be idle 
to hope to counteract the influence of Christianity 
until corresponding institutions could be erected by 
the government." 

Walshe ("Old Time Makers of Medicine") contends 
that "Christianity's influence on medicine instead of 

hampering was most favorable Far from 

Christianity inhibiting culture, it was the most 
important factor for its preservation, and it provided 
the best stimulus and incentive for its renewed 
development just as soon as the barbarous peoples 
were brought to a state of mind to appreciate it." He 
adds: "The Church evidently considered itself bound 
to care for men's bodies as w-ell as their souls." 

"Religion itself was spoken of as a medicine of the 
soul and the body. Christianity was defined as the 
religion of healing. The word salvation had a 
reference to both body and soul." 

The Christian epoch influenced the evolution of 
surgery in two important particulars, viz.: (1) It 
consecrated the scientific spirit, which the epoch of 
Hippocrates created, to the sacred duty of conserving 
human life and relieving human suffering from the 
highest possible motive, the recognition of the basic 
principle of Christianity — the Fatherhood of God and 
the Brotherhood of man — and (2) it preserved the 
records of the experience of the centuries past inviolate 
and encouraged the study and practice of surgery — 
many of the "Fathers of the Church" even bishops, 
becoming eminent practisers. Though the Christian 
Church did not materially advance surgery it served 
as important a purpose by conserving its practice in 
its hospitals and in its monasteries (its literature) 
during the disturbed centuries of the mediaeval 
period. Walsh says: "The Church's first grave duty 
was the preservation of the old records of literature 
and science. Fortunately the monasteries accom- 
phshed this task." But the church not only carefully 
preserved the literature of surgery, but it published 
from time to time important works embodying practi- 
cal and essential matter gleaned from former writers. 

The epoch of Christianity may be regarded as the 
close of the period of antiquity in the history of sur- 
gery. It will prove useful and interesting before 
entering upon the new era to make a note of the stage 
of development which surgery had reached at this 
period. This can be approximately determined by 
the number and variety of instruments invented and 
the character of the operations performed. On the 
variety and use of instruments Billings quotes Susutra 
whose writings he places at 100 B.C. or 700 a.d. and 
remarks: "Recent authorities consider that the later 
•date is the more probable one, and that the work took 
its present form under the influence of ideas derived 
from the Alexandrian School and the early Arab 
writers." 

We select from these writings such statements as 
will enable the student to determine the stage of 
development of the art of surgery at this epoch. 
"Edged instruments are used for eight purposes, viz., 
(1) amputating; (2) opening; (3) _ scarifying; (4) 
puncturing; (5) exploring; (6) drawing; (7) evacua- 
tions; (8) sewing." "A surgeon contemplating to 
operate in any of the above ways should first have 
ready the following: blunt instruments (forceps, etc.), 
sharp instruments, potential cauteries, cathcrs, horns, 
leeches, a dry gourd, a cauterizing needle, stuffing 
materials, strings, board, bandage, honey, ghee, fat, 
milk, oil, soothing decoctions, injections, lotions, fan, 
cold and warm water, a frying-pan, able, steady and 
attached servants." During the operation "Let the 
patient be seated, who has taken very little food, 
offered sacrifices, and made ablutions, with his face 
toward the east. The surgeon should stand with his 
face toward him, and plunge his instrument after the 

Vol. VIII.— 3 



proper incision until matter comes out, and withdraw 
It, avoiding vital parts, vessels, muscles, articulations, 
bones, and arteries. In the case of a large collection 
of matter the incision may be of the breadth of two or 
three fingers even. Incisions are either long, wide, 
even or uneven. An incision, whether long, broad, 
clean, or dependent, is always to be extolled when it 
suits (the purpose and) the occasion. Boldness, 
rapidity of action, sharp instruments, operation with- 
out trembling, fear, or doubt, are always praiseworthy 
of the surgeon. The operation for moles, ascites, piles, 
calculus, fistula, and mouth diseases are to be per- 
formed on an empty stomach." "The instruments 
should be so made that they should be of good finish, 
strong, clean in appearance, with good handles, 
whether they be sharp or blunt." 

The extreme care to have instruments adapted to 
their purpose is seen in the notice of the Svastika in- 
struments which "ought to be about nine inches long; 
their mouths should be respectively like those of a 
lion, tiger, wolf, hyena, bear, elephant, cat. hare, 
antelope, crow, heron dog, jay, vulture, falcon, owl 
kite, cock, crouch, the bee, rat, mouse, or bullock, 
each half being united to the other by a nail of the 
form of a lentil seed, being bent inward at the handles 
like the elephant-drivers' hook. These forceps arc 
recommended for the extraction of splinters lodged in 
bone . . . The lion-mouth forceps is for foreign bodies 
that can be seen while for covered ones there are the 
heron forceps and others of its kind. These should 
be used gently the foreign body being removed in 
accordance with surgical principles. The heron for- 
ceps is the best of all forceps, since its use never leads 
to accidents. It enters easily and is very easily drawn 
back. It lays a firm hold on splinters and removes 
them easily." 

Tubular instruments are described as "of a variety 
of kinds, having various uses, open at one end or both 
or having several foraminae. They are used for re- 
moving obstructions from the great canals of the body, 
or for examination of diseases, or as suction tubes, or 
for easy application of remedies. Their lengths are 
always determined by the aperture of the canal whence 
the obstruction is to be removed or the use to which 
they are to be apphed. It appears that different 
tubular instruments were used in "fistula, hemorrhoids, 
polypi, sores, urethral injections, enemas, retention 
of urine, ascites, inhalation for cough and dyspnea, and 
obstruction of the bowels." 

Probe-like instruments "are of various kinds and 
serve a variety of purposes. Their magnitudes differ 
according to the uses they are applied to. .Among 
them the earthworm-like probe, the arrow probe, the 
serpent-hood probe, and the hook probe are each of 
them two in number. They have been recommended 
for sounding, separating, loosening, and extracting 
(foreign bodies). Probes having lentil-seed-Hke ends 
are two. They are sUghtly curved inward at their 
extremities, and are used for the extraction of foreign 
bodies from the large canals. There are six probes 
which are capped with cotton wool, and are used for 
cleaning and wiping purposes. There arc three which 
are ladle-like and mortar-like, and are used for appli- 
cation of caustics. Three others there arc which have 
their ends like a jambel-seed; three others resemble 
the elephant hook. These six arc u.sed for cauterizing 
purposes. There is a nasal-polypus probe which 
resembles the kolasthi. There is the inunction probe 
which at both extremities has a knob like the pea-seed 
resembling an open bud. There is the urinary cathe- 
ter which resembles the stalk of malati flowers, and its 
length varies according to purpose." 

The writer who most completely describes the opera- 
tions at this period was .Vuliis Cornelius Celsus 
(25 B,c.-50 .\.D.), a Greek resident of Rome. 
He was not a practitioner but an author — an en- 
cyclopedist — who wrote authoritatively on many sub- 
jects. His writings are believed to correctly illustrate 

33 



SurKPry. History of 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



the state of suriiical practice at that period. Baas 
says: "In this work of Celsus much of the substance 
of the lost writings of ancient physicians, and especially 
those of the Alexandrian age, is preserved. He has 
inaiiifestlv selected from these with ripe judgment only 
what is reasonable, useful, and valuable." He says: 
"The (lualitications of the surgeon . . . are a firm, 
steady hand, the ability to use either hand equally 
well, youth, or at least an approximation thereto, a 
.sharp "eye, lack of timidity and cornpassion, so as not 
to be moved by the outcries of his patient. . . He 
describes ... a large number of surgical ailments, 
such as disease of the joints and the bones, 
wounds, tumors, burns, fistula, abscess, sprains, 
and lu.xations, for which he recommends reduction 
before the commencement of inflammation; frac- 
tures, in which, when they fail to unite he recom- 
mends extension and rubbing the ends of the bone, 
and even cutting down upon the bone so that it 
heals as an open wound; hernia which he thinks 
originates in laceration of the peritoneum; strangu- 
lated hernia where he cautions against cathartics, the 
radical operation for reducible hernia by turning up 
and casting a ligature about the neck of sac or com- 
pression of the latter until necrosis takes place (in 
large and strangulated hernia he does not approve 
any operation). 

He notices many operations of the ancients, some 
of them handed down by him alone, as bleeding, 
double ligation of bleeding vessels and division of 
vessels between the ligatures, lithotomy, castration, 
amputation in the sound Ilesh with a single circular 
cut (in gangrene only, a rule which prevailed through- 
out the whole Middle .Vges down to the seventeenth 
century) which he is the iirst among the ancients to 
describe unequivocally, catherization, repair of de- 
fects of the nose, lips, auricles, and prepuce . . . tre- 
panning, the operative treatment of goiter . . . resec- 
tion of the ribs, enema (with the view too of artificial 
feeding) diseases of the ears (which ho only among the 
ancients discusses, and in which he recommends the 
car .syringe, extraction by means of the forceps, fasten- 
ing the teeth with gold wire." 

He describes catheterization .as follows: "This in- 
strument (catheter) is necessary not only in men, but 
also occasionally in women. In order that it may 
fit everybody, whether small or large, the surgeon 
should have tlirce sizes for men and two for women. 
The largest size for men should be fifteen inches in 
length, the medium twelve inches, and the smallest 
nine inches. For women the larger size should be 
nine inches and the smaller six inches in length. The 
instrument should be curved slightly (especially tlie 
male variety) and as smooth as possible, and neither 
too thin or too thick. The patient should be placed 
supine upon a bench or couch, as in the treatment of 
the diseases of the anus. The surgeon st.anding upon 
his right side grasps with his left hand the penis, and 
with the right introduces the instrument into the 
urinary passage. When the catheter has reached the 
neck of tlie bladder, it, with the penis, is to be 
depressed and the point pushed into the bladder, 
and after the evacuation of the urine, it is to be 
withdrawn." 

He arrested hemorrhage by pressing the finger on 
the open vessel until the flow ceases when a properly 
heated cautery is applied until the blood stops; if 
the blood cools the cautery another should be used 
.several of which should be in readiness. He carefully 
avoided applying the cautery to the nerves. He 
speaks of four methods of arresting hemorrhage, viz., 
by the cautery, by completely dividing the vessel so 
1hat the ends may contract and allow the formation of 
blood clots, by ligature and by the application of 
substances which arrest blood, supported by a 
bandage. 

He incised a contracted meatus, dilated strictures 
of the urethra ^\nth lead sounds, suggested operations 

34 



for hypospadias, operated on varicose veins by inci- 
sion or extirpation, cured adherent fingers by dividing 
the adhesions and inserting lead plate to prevent 
union. He proposed treatment of fracture of the 
pelvic arch in women by the introduction of a sheep's 
bladder into the vagina and distending it through a 
tube introduced into its orifice. 

From the preceding quotations it is evident that 
both the art and science of surgery had reached a 
high state of development at this period. It is to 
be noted in this connection that hitherto medicine 
and surgery were cultivated together, a condition 
which contributed to their healthy and symmetrical 
development. 

EXPERI.MENTAL METHODS OF RESEARCH (ClaUdius 

Galen, 131-201 a.d.). — While the prejudice of the 
Romans against Greek medicine was so intense that 
few citizens entered the profession, Rome and its 
provinces furnished an inviting field to enterprising 
physicians of other nationalities. One of the most 
distinguished of this class was Claudius Galen, a native 
of Pergamus, who had received his education at the 
schools of Smyrna, Corinth, and Alexandria. 

G.alen's contributions to surgery were chiefly con- 
fined to his works on anatomy which were text-books 
until the sixteenth century. An interesting feature 
of his teachings was the recognition of the function of 
an organ or part, and then the adaptation of structure 
to function. This is scientific anatomy and even in 
our time does not receive the .attention it deserves. 
In his enthusiasm at the revelation of design, or the 
special fitness of a part for the function it is to perform, 
Galen is said to have cried out, "The study of anat- 
omy is like reciting a hymn to the Gods." Deprived 
of the opportunity of using human subjects in his 
dissections Galen's anatomical studies were largely 
confined to animals and the pig was his favorite, 
especially at his demonstrations. He was the first to 
describe the structure of the tendo Achillis, the 
popliteus muscle, eight other muscles of which two 
were situated on the upper arm and two were niastica- 
tory muscles, the platysma myoides, three coats of 
arteries, the eye and its six muscles, the heart, the 
larynx, and the spleen (Baas). In experimental work 
Baas says that Galen was the first physiologist to 
vivisect and experiment upon scientific principles. 
He founded the physiology of the nervous system by 
section of the fifth cervical nerve after which he saw 
the motility of the supra- and infraspinatus muscles 
cease; after destruction of the spinal marrow he 
observed the loss of the voice. Galen's re.searehes in 
special pathology were useful as he based results on 
experiment. 

Though Galen's contributions to the development • 
of surgery, embodied in his writings on anatomy, were 
learned by the dissection of animals, the scientific 
spirit which characterized his work, as illustr.ated by 
his .search for truth by experimental methods of 
research, made him an undisputed authority until the 
epoch of human anatomy created by Vesalius (1514- 
64). Baas remarks of Galen that he was the dis- 
coverer of many anatomical facts and was always a 
very careful describer, especially in osteology, the 
central and peripheral nervous systems, the larynx, 
the intestines and the genital organs. He adds that 
"Galen is the Father of Teleology in Medicine." 

Galen's surgical wTitings are replete with sugges- 
tions. He mentions forward dislocation of the thigh; 
aneurysms due to dilatation and puncture of the artery ; 
the treatment of .aneurysm by means of compression 
with a sponge a method believed to be modern, and 
also treatment by ligature. In hemorrhage he directs 
the finger to be placed gently upon the mouth of the 
bleeding vessel, extending and compressing it; if the 
wounded vessel lies deep the surgeon *nust learn its 
position and size, and then, whether it be a vein or 
artery, lift it with a hook and twist it a little; if this 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



does not answer, and it is a vein, styptics such as 
roasted rosin, fine flour, gypsum, etc., are to be tried; 
but if it is an artery it must be ligaled or entirely 
divided; also sometimes the veins must be ligated and 
divided and it is safer to do both, that is, to ligate the 
proximal end of the vessel and also divide it beyond 
the ligature. 

The surgeons of the period whose names have 
become historical are as follows: 

Archigenes of Apamea (48-117 a.d.) advocated in 
amputations the preliminary ligation of the main 
vessel and subsequent cauterization of the smaller 
ones; another method of preventing hemorrhage in 
amputations was retraction of the skin above the 
point of operation and the application of a bandage 
tightly._ The surgeons of the Roman period of his- 
torical interest were not numerous. Herophilus and 
Erasistratus of the Alexandrian School, practical 
surgeons but especially famous as teachers of anatomy, 
contributed to the advancement of scientific surgery. 

Rufus of Ephesus (98-117 a.d.) by his dissection 
of apes and other animals made discoveries in the 
structures of the eye, of the nervous system and of 
the heart, and published a small work on anatomy; 
he wrote on the diseases of the kidneys and urinary 
organs. Heliodorus (about 100 a.d.) is reputed to 
have been the first to describe the ligation and torsion 
of blood-vessels, and one of the first to perform inter- 
nal urethrotomy for stricture. In amputation of the 
leg he first made an incision on the aftterior surface of 
the leg and sawed the bone before incising the soft 
parts and the blood-vessels on the posterior part of 
the leg. He discarded chopping off limbs and 
declares amputation through and above the knee- 
and elbow-joint dangerous, an opinion prevalent to 
the seventeenth century. Supernumerary members 
he removed by double circular section. He describes 
trepanning and its after-treatment, caries and necrosis, 
injuries of the head, exostosis and fissures of the skull 
and their treatment. 

Leonidas of Alexandria (about 200 a.d.) is men- 
tioned as one of the most important of the great 
surgeons of the imperial period. "He amputated 
limbs and cancerous breasts with the knife, even 
cutting through the healthy tissues, but treated 
hemorrhage with the actual cautery. In operating 
for empyema he resorted to incision, as well as to 
burning through the chest wall with the red-hot iron. 
In hydrocele he first cauterized and then made an 
incision; he practised scarification in anasarca, 
recommended puncture in hydrocephalus, and found 
the reduction of hernia not very difficult. Fistula, 
especially fistula in ano, he operated upon with a 
blunt pointed knife which he called a syringotome. 
He was the most important syphilographer for 
antiquity." 

Antyllus (third century) ranks as one of the great 
surgeons of antiquity. He described the operations 
of venesection, arteriotomy, cupping, scarification, 
subcutaneous section of the ligaments in stiff joints 
and of the tongue in stammering, tracheotomy, etc. 
He was the first to use depression of small cataract. 
The most interesting feature of Antyllus' writings, as 
given by Oribasius, and which illustrates his charac- 
ter and ability as a practical surgeon is the descrip- 
tion of his method of treating aneurysm — a method 
recognized and practised until Hunter in 1785 applied 
the ligature on the distal side of the artery. 

Billings quotes from Oribasius: "There are two 
kinds of aneurysm. In the first the artery has under- 
gone a local dilatation; in the second the artery has 
been ruptured. The aneurysms which are due to 
dilatation are longer than the others. The aneurysms 
by rupture are more rounded. To refuse to treat 
any aneurysm as the ancient surgeons advised is 
unwise; but is is also dangerous to operate upon 
all of them. We should refuse, therefore, to treat 
aneurysms w-hich are situated in the axilla, in the 



Surgerjr, History of 



groin, and in the neck, by reason of the volume of the 
vessels and the impossibility and danger of isolating 
and tymg them. We should not touch an aneurysm 
of large volume even when it is situated in some other 
part of the body. We operate in the following manner 
upon those which are situated upon the extremities 
and the head: If the aneurysm be by dilat.ition make 
a straight incision through the .skiii in the direction 
of the length of the vessel, and drawing open by the 
aid of hooks the lips of the wound, divide"with 
precautions the membranes which cover the artery. 
With blunt hooks we isolate the vein from the artery 
and lay open on all sides the dilated part of this la,st 
vessel. After having introduced beneath the artery 
a probe, we raise the tumor and pass along the probe 
a needle armed with a double thread in such a manner 
that the thread finds itself placed beneath the artery; 
cut the threads near the extremity of the needle, so 
that there will be two threads having four ends; 
seizing then, the two ends of one of these threads, we 
bring it gently toward one of the two extremities of 
the aneurysm, tying it carefully; in like manner also 
we bring the other thread toward the opposite extrem- 
ity, and in this place tie the artery. Thus the whole 
aneurysm is between the two ligatures. We open 
then the middle of the tumor by a small incision; in 
this manner all which it contains will be evacuated 
and there will be no danger of hemorrhage." 

"To tie, as it has been advised, the artery on both 
sides of the vein, and then to extirpate the dilated 
part which finds itself between, is a dangerous opera- 
tion, frequently, in fact, the violence and tension of 
the pneuma push off the ligatures. If the aneurysm 
owes its origin to the rupture of the artery, we isolate 
with the fingers as much of the tumor a.s we can, in- 
cluding the skin, after which we pass underneath the 
isolated part the needle with the double thread and 
proceed as before; after which the tumor may be 
opened at its summit and the superfluous portion of 
skin cut away." 

On the downfall of the Western Empire (476 a.d.) 
the capitol of the Eastern Empire, Byzantium, be- 
came prominent as the seat of learning. Although 
several surgeons of eminence appeared during the first 
centuries of the Byzantine period their attainments 
were due to their Greek culture rather than to any aid 
derived from local conditions favoring their profes- 
sional advancement. 

Garrison says: "The solitary thing the Eastern 
Empire did for European medicine was to preserve 
something of the language, culture and literary texts 
of Greece. Although the Byzantine power lasted 
over 1,000 years (39.5-1153 a.d.), medical history is 
concerned chiefly with the names of four industrious 
compilers who were prominent surgeons in the first 
three centuries of its existence, viz., Oribasius (326- 
403), .Etius (502-575), Alexander of Tralles (52.5- 
605), and Paul of ^gina (62.5-690)." 

Paul of .(Egina (02.5-690 a.d.) is regarded as the 
most famous surgeon of the Byzantine period of the 
Eastern Empire. He was educated at the University 
of Alexandria and lived for the most part in Egj^it 
and Asia Minor. His surgical writings were authority 
for centuries though he made no claim to originality, 
acknowledging that he compiled his works from ancient 
authors, adding little of his own except a few things 
which he had seen and tried. It appears from his 
writings that he practised scarifications, punctured in 
hydrocephalus, performed paracentesis, used the 
cautery m abscess of the liver and empyema, in her- 
niotomy removed the testicle which was practised into 
the sixteenth century, removed the breast for cancer, 
extirpated the uterus, incised in hydrocele, applied 
two ligatures to veins in varicocele which caused 
sloughing of the intermediate portions, performed 
clitoridectomy in nymphomania, used a speculum in 
disease of the uterus, operated for imperforate anus, 
performed amputations (Baas). 

35 



SurKcry, History of 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



III frsH'turcs he aclvisi'S iinrnodisite uso of splints and 
frequent ehange; rcfracliire in badly united fractures, 
even to the use of the chisel; pressure in straightening 
calhis; describes machines for correcting crooked 
growth. 

Baas says: "The military surgery of Taul is very 
complete, clear and suited to the weapons of the period. 
It is evidently based on a rich experience for he had 
seen even the" worst injuries do well." He concludes 
that "Paul must have been one of the most capable, 
if not the most important, of the surgeons among the 
Greeks and certainly the most daring operator among 
them." 

The Mediev.\l Period (470-900 a.d.).— The Nletlio- 
val Period was an epoch of disaster to the existing 
civilization. Its dominant feature w:us the decline of 
learning and the reign of the vices of ignorance and 
superstition due to the inva.sion of the Roman prov- 
inces bv the wild Northmen, the conquests of Moham- 
medantsm in Asia Minor and Spain, and, finally, 
the vast disturbances created among the nations en- 
gaged in the crusades. The Medieval Period has been 
described as the expiring struggle of ancient civiliza- 
tion and the birth of the Christian Epoch or modern 
civilization. 

Baas says: "The creation of a new civilization in 
place of the decayed and stagnant culture of the 
ancients was then" the diincult task of the Middle 
Ages. From a spiritual i)(iint of view it was the 
result of unprecedented struggles concerning the new 
feelings and thoughts awakened b}' a new and Christian 
philo.sophy and a new faith." 

The history of surgery during that period was 
characterized by conservation rather than progress, 
and though it was under the depressing influence of 
Roman prejudice from its introduction to Rome (146 
B.C.) to the downfall of the Western Empire (47r) 
A.D.) its darkest period was between the latter date 
and the origin of the medical school of Salerno in 
Italy in the tenth century — formally constituted a 
university by Ferdinand II (1213 .\.D.). 

It is an interesting fact that while the destructive 
forces of this period were dominant, surgery found in 
the religious orders that spirit of conservatism essen- 
tial to the preservation of its traditions. While, there- 
fore, little substantial progress was made nothing of 
intrinsic value was lost. The Medieval Period fur- 
nishes to the student of surgical history no other 
features of special interest than a knowledge of the 
conditions which during that period protected the art 
and science of surgery from the general disaster. 

We have already noticed the fact that during the 
Roman Period (146 B.C., 476 a.d.) surgery as a 
profession was discarded by the higher classes and 
relegatefl to barbers anrl bathers, though they tolerated 
and even patronized Greek surgeons. We .attributed 
to this latter incident the conservation of the tradi- 
tions of surgery and the high grade of practice main- 
tained, during the early centuries of the Medieval 
Period. 

The first and most important factor in the protec- 
tion of surgery from the destructive forces of the later 
centuries of the Middle Ages was the spirit of conser- 
vatism of the sciences and the humane institutions 
of the period by the Church and the monasteries. 

Walshe's able review of this period is very enlighten- 
ing as to the relations of Christianity to the sciences 
and especially to the preservation of those of medicine 
and surgery. He says: "The decadence of the early 
Middle .\gcs was due to the natural shifting of masses 
of population of this time, while the salvation of 
scientific and literary trarlitions was due to the one 
.stable element in all these centuries — ^the Church. 
Far from Christianity inhibitng culture, it was the 
most important factor for its preservation. 

The service which the Church rendered to medicine 
and surgery he thus explains: "The Church's first 

36 



dut}' was the preservation of the old records of litera- 
ture and of scieni'e. Fortunately the monasteries 
accomplished this task, which would have been ex- 
tremely i)erilous for the precious treasures involved 
but for tlie favorable conditions thus afforded. . . . 
Monasteries . . . were built very substantially and 
very simply, and the life in them formed the best pos- 
sible safeguard against fire which worked so much 
havoc in cities. Not only were the old records pre- 
served, but excerpts from them were coll.ated and dis- 
cussed and applied by means of direct observation." 

Another conservative force during the Medieval 
Period was the Jewish physician. During the Middle 
Ages the Jews were very prominent as practising 
physicians and instructors. They were among the 
teachers of the Arabs in the East, and of the Moors in 
Spain, and were probably among the first profes- 
sors at Salerno as well as at Montpellier. Many 
prominent rulers and ecclesiastics selected Jewish 
physicians. 

Billings says: "The kings and the great nobles, 
including some of the bishops, resorted to Hebrew 
physicians, who during the tenth and eleventh cen- 
turies were almost the only persons who possesseri 
medical learning or who wrote on medical subjects. 
A Jewish physician in those days was a sort of contra- 
band luxury. Both Catholic and Mohammedan rulers 
resorted to him when anything like scientific knowl- 
edge was required. ... It should be noted that 
the preference ti'as for Jewish physicians as being 
Jews." . . . 

A third conservative force was due to the Arabian 
influx into Italy and Spain after the capture of Alex- 
"andria by the Muhaiuinedans (640 a.d.). The con- 
quests of the Mnhanunedan Arabs in Asia Minor and 
Spain brought these wandering tribes into contact 
with Greek and Christian culture. Walsh says : 
"Captive Greece took its captors captive. What hap- 
pened to the Romans earlier came to pass also 
among the Arabs. Inspired by Greek philosophy, 
especially that of Aristotle, they became ardent devo- 
tees of science and the arts. While not inventing or 
discovering anything new, like the Romans, they car- 
ried on the old." An important feature of this awak- 
ening of the oriental mind to an appreciation of 
learning led to the establishment of centers of educa- 
tion and the collection and preservation of scientific 
literature in libraries. Medicine as a philosophy of 
health attracted especial attention and its literature 
was carefully preserved and its tenets taught in the 
schools. 

A disturbing element in the progress of surgery 
which had its origin in the prejudices of the Roman 
people against Greek medicine became dominant 
during the later Medieval Period And must be noted, 
viz., the rise of the "barber surgeons." The physi- 
cians of the period were of the priestly class and 
abhorred the shedding of blood, while the barbers 
were the ordinary surgical operators. The Romans 
had declared that surgery was a menial handicraft, 
unfit for the nobility but adapted to the functions of 
barbers and bathers. This prejudice was intensified 
by the arrogance of the priests who were in intimate 
relations with the ruling classes, and who sought 
everywhere to control the policies of governments in 
relation to the practice of medicine and surgery. 
The result was that the barber surgeons became a 
power for centuries in France, Germany and Great 
Britian and influenced unfavorably the progress of 
scientific surgery. In France they were divided into 
two classes in the middle of the thirteenth century, viz., 
the ordinary or lay barber, afterward known as "barber 
surgeons" or "surgeons of the short robe;" and the 
"clerk barbers" or "surgeon barbers," "the surgeons 
of St. Come," or "surgeons of the long robe," who 
sought to be independent of the ordinary barbers, to 
monopolize surgical operations and to raise their 
Guild to the rank of a profession. The Guild of the 



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Surgery, BIstonr of 



surgeon barbers was organized in 1268, six surgeons 
being selected to examine and license those who 
wished to practise, more especially barbers. 

In England the barber surgeons were chartered as a 
company in 1401, but the charter did not prohibit 
other persons from practising surgery in London. In 
1512 a new charter was granted which forbade the 
practice of surgery by others than members of the 
company of barber surgeons inside the City of London 
and within seven miles of the same. In 1540 there 
was an effort to separate the duties of surgeons and 
barbers by an act of Parliament which provided that 
"no person using any shaving or barbery in London 
shall occupy any surgery, letting of blood or other 
matter, except only drawing of teeth." Surgeons 
were prohibited from practising shaving. In 1745 an 
act was passed separating the surgeons from the bar- 
bers which resulted in the final downfall of the hier- 
archy of barber surgeons. 

The following were the more notable surgeons of 
the period: 

jEtius (502-576 a.d.) of Amida, in Mesopotamia, 
was the first great Christian surgeon. He was edu- 
cated in the School of Alexandria and lived in Byzan- 
tium. He became physician to the Emperor Jus- 
tinian I. His WTitings on surgery show an advanced 
stage of practice. He mentions ligation and torsion 
of vessels to arrest hemorrhage. In the cure of vari- 
cose veins he applied two ligatures and excised the 
dilated portion followed by a light bandage. He also 
applied the cautery at intervals on the distended part. 
Foreign bodies in the larynx he removed by inducing 
sneezing or coughing and if in the esophagus, and 
could not be reached by forceps, the patient was 
either to swallow mouthfuls of fresh bread to force the 
mass into the stomach or an attempt should be made 
to have him swallow a well-greased sponge, or piece 
of meat to which a string is attached. He distin- 
guishes between rodent ulcers and cancer, and the 
latter he says is more frequent in women than in men. 
In operations for cancer he quotes from Leonides the 
necessity of extensive removal of tissue and the free 
use of the cautery to destroy any remaining diseased 
tissue — quite modern methods. 

jEtius was obsessed with Christian superstition as 
appears from his method of treating foreign bodies in 
the esophagus, which was to seize the patient by the 
throat and cry in a loud voice, "As Jesus Christ drew 
Lazarus from the grave; and Jonah out of the whale; 
thus Blasius, the MartjT and servant of God, com- 
mands, 'Bone come up or go down'!" The surgical 
writings of Jitius were popular for centuries though 
largely copied from previous '^Titers. Cornelius re- 
marks that if one "would have the whole of Galen 
abbreviated and the whole of Oribasius extended, and 
the whole of Paulus (of ^gina) ampUfied all the 
special remedies of the old physicians ... in surgery 
boiled down to a summary, he will find it in jEtius." 

Rhazes (850-923 a.d.) was a native of Raj, 
Province of Chorasan, Persia, and studied at Bagdad. 
By direction of the Sultan he had charge of the en- 
larged hospital at Bagdad. His principal surgical 
writings were largely quotations from Oribasius, Paul 
of iEgina and ^Etius, with original observations on a 
variety of subjects, as hernia. Malgaigne says that 
Rhazes was the first to mention a 7nelal band in con- 
nection with a truss. In wounds of the abdomen 
with protrusion of the intestines which it is difficult to 
replace, he advises suspension of the patient by his 
hands and feet in a bath with the application to the 
intestines of comjiresses wet with warm wine. The 
writings of Rhazes were in great repute for centuries. 
_ The .\rabians contributed to the revival of scien- 
tific surgery through the institutions of learning 
which they had acquired by their conquests in Egypt, 
Asia Minor and Spain, and which they not only 
continued but to which they added others. The 
schools of Alexandria, Tarsus, Cos, Cnidos, Pergamos 



were thus preserved and the most famous added were 
tlie schools of Bagdad in the East and Cordova in the 
West. Hence, it has been alleged that the teaching 
in Salerno was Arabian, but there is evidence that it 
was chiefly Grecian. This opinion is confirmed by 
Hyrtl, "Rarer Old Anatomists" who says: "The 
.A.rabs paid very little attention to anatomy," and . . . 
because of the prohibition of the Koran, added nothing 
to it. '\\Tiatever t hey knew they took from the Greek.s, 
and especially Galen. Not only did thev not add 
anj'thing new to this, but they even lost sight of much 
that was important in the older authors. . . . They 
delighted in theory, rather than in observation." 
.\li .4bbas (tenth century) described the treatment of 
a wound of the artery in venesection from the median 
basiUc vein, \-iz.: careful isolation of the arterj' by dis- 
section and the application of a ligature above and 
another below the wound and then complete division 
of the vessel at the seat of the wound. In ascites, he 
directed that an opening be made in the abdominal 
wall with a lancet three fingers breadth below the 
navel and, after the evacuation of a portion of the 
fluid, the insertion of a tube through which a certain 
amount of fluid is allowed to escape from time to time 
until the cure is effected. From the preceding sketch 
it appears that though little progress in the develop- 
ment of surgery was made during the period of the 
Middle Ages prior to the tenth century, it had not lost 
the scientific spirit which has characterized its prog- 
ress at all times, and under all conditions. The long 
period of conservatism through which surgery had 
passed seems to have prepared it to enter with renewed 
energy an epoch of education. The time, place and 
promotors of such an epoch seem to have been wisely 
chosen in the organization and management of the 
Medical School of Salerno. 

The Medical Schoolof Salerno (About 900 a.d.). — 
This epoch was characterized by tlic establishment 
of schools of learning and universities. The debris of 
the ancient and now destroyed civilization was to be 
removed and new generations were educated and 
adapted to the duties of the future constitution of 
society. The initial movement in this preparation so 
far as it affected the progre-ss of surgery began with the 
Medical School of Salerno about the beginning of the 
tenth century. Salerno was a small sea-side town 
near Naples, Italy. It had been a famous health- 
resort of the Romans from an early period. A hos- 
pital was among its public institutions 820 a.d., under 
tlie management of the Benedictines. Other chari- 
ties were added from time to time and thus the sick 
were attracted to Salerno from all parts — Arabs, 
Jews, Mohammedans, Christians, Greeks. At one 
time crusaders sought the cure of their injuries and 
diseases at Salerno. Naturally, high-grade physicians 
and surgeons were called to attend them and many be- 
came permanent residents. 

The school began to attract attention at the begin- 
ning of the tenth century. Its origin is attributed to 
four persons, called "The Four Masters," viz., Elinus, 
a Jewish Rabbi; Pontus, a Greek; Adala, an .\rabian; 
Salerno, a Roman Magister. 

In its origination and teachings the School of Sal- 
erno created an epoch in the teaching of medicine and 
it ushered in the era of modern scientific in phicc 
of ancient, empirical, practice. W'alshe says: "It 
brought about in the course of its development an 
organization of medical education, and an establish- 
ment of standards that were to be maintained when- 
ever and wherever there was a true professional si)irit 
down to our time. They insisted on a preliminary 
education of three years of college work, on at least 
four years of medical training, on special study for 
special work, as in surgery and on practical training 
with a physician, or in a hospital, before the student 
was allowed to practise for himself." These stringent 
but altogether rational regulations, which are not 

37 



Surgery, History of 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



cxcollfd by the best medical schools of to-tlay, were 
so popular that the authorities proceeded to en- 
force them bv legal enactments. Thus the Medical 
School of Salerno not only became famous as the 
epoch-making force in the new era of the development 
of the medical sciences, but it attracted other depart- 
ments (if learning which resvilted in its becoming a 
universitv, bv roval edict, in 1213. 

The resources of the School of Salerno, as a centex of 
instruction in surgery, were greatly improved by Con- 
stantine .\fricanus, a native of Carthage (1018-108.'j), 
who was devoted to the collection of scientific works. 
In extensive travels he collected and preserved a large 
amount of the most important medical literature then 
accessible. On being called to the School of Salerno 
as a professor this literature became available to the 
teachers and pupils and thus gave a high character to 
the instruction in all branches. After ten years 
service as a professor Constantine became a Benedic- 
tine monk and retired to the monaster}' at Monte 
Cassino where he prepared much of the medical litera- 
ture which is attributed to him. 

As the Arabs by their conquests h.ad been brought 
into immediate contact with Grecian physicians in 
the Greek cities of .\sia Minor tlicy were more familiar 
with the medical sciences than the scholars of the 
West. "What was best in .Arabian medicine" says 
Walsho, " was brought to Salerno by Constantine and 
his translation of many well-known Arabian medical 
authors proved eminently suggestive to seriously 
investigating physicians all over the world." Pagel, 
quoted by Walshe ("Puschmann's Handbook"), 
says, "a further merit of Constantine must be recog- 
nized, inasmuch as that not long after his career the 
second epoch of the school of Salerno begins, marked 
not only by a wealth of writers and writings on medi- 
cine, but, above all, because from this time on the 
study of Greek medicine received renewed encourage- 
ment through the Latin versions of the .\rabian litera- 
ture. We may think as we will of the worth of these 
works, but this much is sure, that in many ways they 
brought about a broadening and an improvement of 
Greek knowledge." 

The distinguishing features of the School of Salerno 
were both in the subjects taught and the method of 
teaching. The subjects taught were the most ad- 
vanced then known in the art and science of surgery, 
and were made available to the teaching faculty by 
the collection of literature contributed by Con.stantine. 
The method of teaching was in a legally organized 
school which admitted only qualified stiidents and 
required a fixed term of .study and a high grade of 
scholarship for graduation. Walshe says the school 
of Salerno standardized medical teaching and adds: 
"The most important contributions to medical science 
made by the Medical School of Salerno, at the height 
of its development, were in surgery." 

The epoch which the School of Salerno created was 
distinguished for the high grade of its teachings due 
largely to its intimate association with the rising uni- 
versities. In this regard it laid securely the founda- 
tions of the teaching of scientific surgery. Baas 
speaks of the dominance of the School of Salerno as 
the "Scholastic Period." 

Created and finally endowed as a university this 
school was in a position to exert a wide and popular 
influence on the progress of the medical sciences. 
Students were attracted to it from distant countries 
who, on returning, estabUshcd schools of medicine in 
the Universities of Italy, Spain, and France on the 
basis of that at Salerno. Several of these became 
famous as centers of surgical instruction, viz., Bolonga, 
Reggio, and Mocena in the twelfth centurv; Vicenza,' 
Padua, and Naples, in the thirteenth centurv; Rome, 
Pisa, and Florence in the fourteenth century. The 
representative surgeons of Salerno and the more promi- 
nent universities of southern Italv maintained for 
centuries the high standards of instruction of the 

38 



schools with which they were connected and through 
their pupils transmitted them to the northern States of 
Europe. 

The most important work on surgery emanating 
from the School of Salerno was by Roger of Parma 
(about 1210) who had been one of its pupils and pro- 
fessors. His work "Practica Chirurgise" is said to 
have formed the real basis of the medieval surgery of 
Italv, though he borrowed from Albucasis and Paul of 
.EgiiKi (Baas). 

Walshe, however, says: "Apart from Greek sources 
Roger's book rests entirely upon his own experiences, 
those of his teachers and colleagues, and the tradi- 
tions in surgery that had developed at Salerno. This 
tradition was entirely from the Greek." He quotes 
from Roger as follows: "We have resolved to write 
out deliberately our methods of operation such as 
they have been, derived from our own experience and 
that of our colleagues and illustrious men." 

Roger was the first to mention hernia pulmonis; 
described trepanning of the sternum and stitching of 
the intestine over a hollow cylinder. He was an 
advocate of moist dressings in the treatment of 
wounds or healing by second intention; he employed 
the seton; advised the ashes of the sponge and -sea- 
weed (iodides) for goiter and scrofula; taught the use 
of the ligature in hemorrhage. 

Rolando, of Parma (about 1250), a pupil of 
Salerno and professor in the School of Bologna, wrote 
a commentary on the works of his master, Roger. He 
practised excision of chancres, scrofulous glands and 
goiter. Later (about 1270) the "Four Masters" 
of Salerno, as they were called, probably surgeons 
living together in the style of the monks, issued a com- 
mentary on the writings of these surgeons which has 
been regarded as the ablest of the medieval works on 
surgery. Gurlt, referring to this final work, says: 
"in spite of the fact that there is some doubt about the 
names of the authors, this volume constitutes one of 
the most important sources for the history of surgery 
of the later Middle Ages and makes it very clear 
that these writers drew their opinions from a rich 
experience." 

Following Roger and Rolando and the "Four 
Masters" in southern Italy was a group of surgeons 
of northern Italy, educated at Salerno, who became 
prominent as teachers and authors and through whose 
efforts we trace the progress of surgery northward to 
France and even England. First was Bruno of 
Longoburgo (1252) of Calabria, who studied at 
Salerno and became a professor at Padua. Baas 
speaks of him as, "A man of ointments, though he 
did not shrink from lithotomy, and treated goiter, etc., 
by operation." He wrote two works on surgery — 
major and minor — which were compiled from the 
Greek and were very celebrated. He advocated the 
healing of wounds by first intention the "dry method " 
of that day, and to this end he adopted absolute 
cleanliness of the wound, even avoiding the use of 
water and secured drainage by position and tents. 

Theodoric (1205-1298), of Cervia, was a Dominican 
monk and later Bishop of Cervia. He was a son of 
the eminent physician, Hugh of Lucca, and wTote a 
text-book of surgery with his full name and title as 
bishop. He also practised the dry healing of wounds 
by the use of the ligature and the appHcation of wine 
and water; he used soft bandages instead of wooden 
splints and secured narcotism of the patient to be 
operated upon bv means of opium and hyoscyamus. 

William of Salicet (1201-1280) was a pupil of 
Bruno and became a professor at Bolonga and 
Verona. His surgical WTitings were remarkable for 
that period in that he quoted little from old authors, 
but recorded his own experience. He was an advo- 
cate of the combination of medicine and surgery in a 
practiser, believing that the physician learned much 
by seeing the interior of the body during life, while 
the surgeon was more conservative if he were a phy- 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



Surgery, Hlstorjr of 



sician (Walshe). Billings speaks of William of 
Salicet as the greatest surgeon of his century and it 
is certain that he represented the highest attainment 
of Italian surgery of that period. The introduction of 
Italian or modern surgery into the northern countries 
was naturally effected through the medium of their 
students, who recei\ed their education in the Italian 
medical schools. 

In France surgery was at this time in a transition 
state and it was largely through the introduction of 
the teachings of William of Salicet that it assumed a 
scientific character. From Baas we learn that 
medicine and surgery were entirely separated in its 
schools the latter being regarded as inferior. From 
an early period, the surgeons were a distinct class, 
having their own special college and guilds of inferior 
and superior surgeons, the former being subordinate 
to the latter, and both were under the control of the 
physicians or "Faculties." The most important 
and influential in the development of modern surgery 
was the ''College de Saint Come." Its organizer and 
president was the royal surgeon Jean Piturd (12'2.S- 
1315). The members had already separated from 
the barbers and formed a guild of superior surgeons, 
but though a high grade of guild-surgery was thus 
attained it was held in little esteem scientifically. 
This defect was supplied from the Italian schools. 

Lanfranc-Lanfranchi (died about 1315), a native 
of Milan, was prominent in introducing Italian sur- 
gery into France. He was a pupil of the famous 
William of Salicet and was compelled through political 
disturbances to leave his country. He located at 
Lyons where he gained such a reputation that he was 
invited to lecture in Paris. He became a member of 
the "College de St. Come" and his lectures were 
attended by throngs of pupils. One feature of his 
lectures especially attractive to .students was that he 
invited them to the bedside of the patient and thus 
established clinical teaching. By his lectures and 
writings _ Lanfrano has the reputation of being the 
pioneer in lajang the foundations of scientific and 
practical surgery in France. He wTote treatises on 
major and minor surgerj' which Gurlt regards with 
great favor. 

Monde ville (1260-1320), a native of Normandy, was 
a contemporary of Lanfranc and aided him in the 
promotion of the new era in surgery. He was a 
pupil of Theodoric of Italy and of Pitard of Paris. 
He first lectured at Montpellier and subsequently at 
Paris. He promoted the study of scientific anatomy. 
His writings on surgery were held in high esteem owing 
to their thoroughly practical character in all details. 
Walshe states that " Mondeville diWdes surgeons 
of this period into three sects: "first, that of the 
Salernitians, with Roger, Roland, and the Four 
Masters; second, that of William of Salicet and Lan- 
franc; and third, that of Hugo de Lucca and his 
brother Theodoric and their modern disciples." The 
characteristics of these sects are given as follows: 
"The first limited patients' diet, used no stimulants, 
dilated all wounds, and got union only after pus for- 
mation; the second, allowed a liberal diet to weak 
patients, though not to the strong, but generally 
mterfered with wounds too much; the third, believed 
in a liberal diet, never dilated wounds, never in- 
serted tents, and its members were extremely careful 
not to complicate wounds of the head by unwise 
interference." 

Guy de Chauliac (1300-1370) was a native of 
Chauliac, on the borders of .\uvergne, France. He 
was educated for the service of the Church, but 
studied medicine in the Universities of Paris, Mont- 
pellier, and Bolonga. The latter place was famous for 
its instruction in anatomy, while Paris was reputable 
for its surgery. He traveled extensively and prac- 
tised surgery at Lyons and other places, and on being 
appointed Chaplain to Pope Urban V., he located at 
Avignon. 



In 1363 his "Chirurgia Magna" was written which 
for a long period was the surgical authority of France. 
Baas regards his surgical treatise as marked by his- 
torical comprehensiveness and critical judgment, by- 
freedom from subtilities, by truthfulness in respect to 
the author's own observations, and by high estimation 
and knowledge of anatomy. He performed venesec- 
tion according to the seat and grade of the disease, 
opened boldly deep-seated abscesses, slit up fistula;, and 
employed compressive bandages in ulcers. In caries, 
anthrax and all suitable lesions he used the actual 
cautery, especially in open cancer, which he declared 
allied to leprosy; but non-ulcerating cancer he cut out. 
His treatment of injuries of the head were conserva- 
tive, the trephine being used when necessary, but ac- 
cording to rules which he gave. As a caution against 
its too free use, he states that he has seen cases re- 
cover where there has been a loss of brain substance. 
He advised suturing of wounds of the intestine and 
describes the kind of suture and invented a special 
needle-holder. 

Walsh quotes the following passage in Guy's 
account of amputation referring to the use of anes- 
thetics, viz., "Some prescribe medicaments which 
.send the patient to sleep, so that the incision may not 
be felt, such as opium, ivy, hemlock, lettuce. A new 
sponge is soaked by them in these, juices and left to 
dry in the sun; and when they have need of it they 
put this sponge into warm water and then hold it 
under the nostrils until he goes to sleep. Then they 
perform the operation." 

Guy deplored the separation of phj-sicians from 
surgeons, a union which exi.sted to the time of 
A\-icenna, sa>-ing, "since that time, either because 
of the fastidiousness or excessive occupation of the 
clerics, surgery has become a separate branch and has 
fallen into the hands of the mechanics." 

The surgical wTitings of Guy de Chauliac were of 
such an authoritative character, though largely 
compilations, that he has received the title of "'The 
Father of Modern Surgery." Garrison regards him 
as "on the whole a reactionary in the important mat- 
ter of the treatment of wounds and by his great 
authority, threw back the progress of surgery for some 
six centuries, giving his personal weight to the doc- 
trine that the healing of a wound must be accom- 
plished by the surgeon's interference — salves, plas- 
ters, and other meddling — rather than by the healing 
power of nature." 

In Germany surgery (Garrison) began with a 
surgical work of a Bavarian army surgeon — von 
Pfolspeundt — wTitten in 1460; he is described as a 
wound surgeon without skill in major operations, 
which he left to the cutters or "incisors;" and he did 
not know how to treat fractures or dislocations. His 
military experience gave him large practice in arrow 
wounds; he makes the first faint allusion to "powder 
burns," and to the extraction of bullets by means of 
the sound; treated wounds by second intention; used 
the narcotic recommended by Theodoric. This 
surgeon was followed by two .\lsatian army surgeons, 
natives of Strassburg — von Gersdorff and Brun- 
schwig. The latter gave the first account of gun-shot 
wounds in surgical literature; regarded such wounds as 
poisoned and removed the poison by promoting suppur- 
ation, usually by means of the seton. He performed 
no major operations, confining himself to wounds, 
bone-setting, and amputation; applied the actual 
cautery, or boiling oil, to check hemorrhage. His 
book was published in 1497. Gersdorff's work was 
published in 1517. He treated fully of gun-shot 
wounds and did not regard them as poisonous; 
probed for the bullet with special instruments and 
poured hot oil into the wounds. In amputation, he 
con-stricted the limb by a band as did Esmarch. with 
his rubber band, subsequently ; checked hemorrhage by 
a cautery of his own demising, completing the operation 
by covering the stump with the bladder of an animal. 

39 



Murxcry, History of 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



In ICiit'land, John of Arilcrnc (130(>-90) was tlic 
curliest of the surgeons; jirobiibly cclut-ated at tlic 
Medical School of MontpcUicr, which was in close 
affiliation with the Scliool of Salerno. ^ 

Of d'Argelata (1423 died), Garrison says: Guys 
most distinKuisliod pupil became professor at Bologna; 
his Chirurgia was printed in 14S0. He taught the dry 
treatment of wounds and used sutures and drainage 
tubes." ■ , • T- 

The most important of the early surgeons m Eng- 
land W!is Thomas Linacre (1460-1524), who became a 
priest and was physician to both Henry VII and 
Henry \111. He wiis graduated at the University of 
Padua, Italy. He made translations of Galen's writ- 
ings on hygiene, therapeutics, temperaments, the 
pulse, and semeiology. He was called by Fuller, the 
"restorer of learning in England." His foundations 
of lectures on medicine at Oxford and Cambridge 
(1524) were valuable in establishing medical education 
in England. 

In the low countries at this period, Yitornuui 
(129.5-1351) was an authority on surgery; a pvi|)il of 
Lanfranc and an ardent supporter of his master's 
teachings, especially in regard to ligation and torsion 
of arteries. 

HrMA.N .\.N.\TO.MY .^s A SCIENCE (Andre.as Vesalius, 
1514-1504). — The great awakening, from the stupor 
of the Middle -■^gcs, the real Renaissance, occurred 
early in the si.xteenth century. Two great epochs 
in the history of surgery 
followed in quick succes- 
sion, each tending power- 
fully to give to its practice 
a high grade of scientific 
precision. 

The fir.st event was the 
introduction of human an- 
atomy. Hitherto, the 
])ractice of surgery was 
based on the anatomical 
works of Galen, but Galen's 
an.atomy was that of the 
animal, e.specially of the 
hog. It is surprising that 
surgeons of the past ven- 
tured to perform the opera- 
tions that they record, with 
such imperfect guides, and 
Fia. 4698. — Andreas Vesalius. it is remarkable that they 
had such favorable results. 
Vesalius, a native of Brussels, descended from a long 
line of distinguished physicians. He was educated at 
Louvain and subsequently went to Paris where he was 
the pupil of men eminent in their profession, one of 
whom was Sylvius, the discoverer of the aqueduct 
bearing his name. Servetus, who became fanums by 
being burned to death as a heretic at the direction of 
John Calvin, was one of his fellow students. On re- 
turning to Louvain in his twentieth year he stole a 
human skeleton from the gallows and pursued his now 
favorite study of human an.atomy. He next entered 
the military service as surgeon and continued his 
investigations on the dead. .'Vt the age of twenty- 
three, he became professor of anatomy at Padua, and 
afterward taught at Pisa and Bologna. He published 
his first work on anatomy in 1543 and it differed so 
much from the writings of Galen, that it met wilh 
opposition from every quarter. Even his former 
preceptor, Sylvius, opposed him. He became J)liy- 
sician to Emperor Charles V and later to Phillip II 
of Spain, but persecution followed him. He died on 
his return from a pilgrimage to Jerusalem on the Island 
of Zante as the result of an .accident from shipwreck; 
he had been recalled as a professor to Padua. 

During the quadricentennial of the birth of Vesa- 
lius — January 7. 1915^the New York .\cademy of 
Medicine collected and exhibited: (1) the works of 

40 




pre-Vesalian anatomists, twenty-three in number; (2) 
the works of Vesalius, ten in number; (3) posthumous 
editions— followers and imitators, sixteen in number. 
The most important of his works is entitled, "De 
Humani Corporis Fabrica," 1543. One of Edison's 
publications illustrated Vesalius' method of demon- 
strating the action of muscles with the following re- 
nuirks: "His tests of the functioning of the recurrent 
nerves are most in.structive as also his method for 
artificial respiration when the chest has been opened — 
a century and a half before Robert Hook to whom 
artificial respiration is generally credited. \'esalius 




stratioii cif the Actii 



of Muscles and Tendo 



further shows insight into the mutual relations be- 
tween the respiration and the action of the heart. 
.\mong the other points he noticed is the lower position 
of the stomach after a meal." The same publication 
gives an illustration of Vesalius' equipment for the 
study of anatomy and physiology. 

In estimating the work of Vesalius, Baas states that 
Mondino (1276-1326) h.ad already made a beginning 
in the erection of the science of anatomy on the basis of 
the examination of the human cadaver, but it was not 
until the sixteenth century that it advanced rapidly 
and became independent of the doctrines of Galen. 




!• i(i. 4700. — \*esalius' Complete Equipment for the Study of 
Anatomy and Physiology. 

In this work Vesalius took the lead of all others ; he it 
was who first, and for a long period alone, boldly and 
persistently combated by facts the popular reverence 
for the authority of Galen's animal anatomy, eradi- 
cated it, if not among all his contemporaries, at least 
for the future. Baas adds that, "In this task he was 
the first to employ wood-cuts drawn after nature in 
illustrations of his .anatomical works." This state- 
ment is of doubtful authenticity. 

The LiGATiTBE in the SnppRESsioN of Hemorrhage 
(.\mbroise Pare; 1510-90). — Thesecond epochal event 
of the sixteenth century was the permanent employ- 
ment of the ligature of vessels in the control of hem- 
orrhage. Billings states that Celsus' directions that 



REFERENCE HANDBOOK OF THE MEDia\L SCIENCES 



the veins and arteries must be secured by a ligature 
at tlie groin and divided behind it, is the first mention 
of the ligature of blood-vessels in published literature. 
He adds that it was an invention of the Alexandrian 
School and was said to have been introduced at Rome 
by Euelpistus. The ligature did not become a recog- 
nized method of suppressing hemorrhage, a substitute 
for the cautery, for fifteen centuries. It was occasion- 
ally mentioned and its use taught, as at the School of 
Salerno, but it did not gain its position as one of the 
epoch-making events for upward of ten centuries. 
Like so many great discoveries the initial stage of its 
development was due to an accident. 

.\mbroise Pare was the son of a country barber of 
France, and, though of humble origin and deprived of 
the advantages of learning, he won by his genius the 
title of "Father of Modern Surgery." He became 
a barber surgeon and on witnessing the operation of 
lithotomy determined to become a surgeon. He 
entered Hotel Dieu as a dresser and there learned the 
art. He enlisted in the army and on one occasion 
there was no hot oil with which to arrest the hemor- 
rhage of a wound and he applied ligatures, as recom- 
mended by Galen witli success. 

Pare makes the following statement of his experiences 
in the treatment of gun-shot wounds by the old meth- 
ods and the incident which led to his use of the ligature 
to the vessel : "To tell the truth, I was not very expert 
at that time in matters of chirurgery, neither was I 




4701. — Par6 Demonstrating the Use of the Ligature in Arrest- 
ing Hemorrhage. 

used to dress wounds made by gun-shot. But I had 
read in John de Vigo that wounds made by gun-shot 
were venenate or poisoned, by reason of the gunpowder ; 
wherefore, for their cure, it was expedient to burn or 
cauterize them with oil of elders, scalding hot, with a 
little treacle mixed therewith. But, since I gave no 
credit neither to the author nor remedy, because I 
knew that caustics could not be poured into wounds 
without excessive pain, I determined, before I would 
run a hazard, to see whether the chirurgeons who 
went with me in the army used any other manner of 
dressing to these wounds. I observed and saw that all 
of them used that method of dressing which Vigo 
prescribes, and that they filled as full as they could 
the wounds made by gun-shot with tents and pledgets 
dipped in this scalding oil at the first dressing, which 
encouraged me to do the like to those who came to be 
dressed by me. 

" It chanced, on a time, that by reason of the multi- 
tude that were hurt, I wanted this oil. Now, because 
there were some few left to be dressed, that I might 
seem to want nothing, and that I might not leave 
them undressed, I was forced to apply a digestive, 
made of the yolk of an egg, oil of roses, and turpentine. 
I could not sleep all that night, for I was troubled in 
mind, and the dressing of the preceding day troubled 
my thoughts, and I feared that the next day I should 
find them dead, or at the point of death, by the poison 
of their wounds, which I had not dressed ^\-ith scalding 
oil. Tlierefore, I rose early in the morning and visited 



Surgery, History, of 



my patients ; and, beyond expectation. I found such as 
I had dressed with a digestive only, free from vehem- 
ency of pain, to have had good rest, and that their 
wounds were not inflamed or tumefied; but on the 
contrary, the others that were burnt with the scalding 
oil were feverish, tormented with much pain, and the 
parts about their wounds were swollen. When I had 
many times tried this, on divers others, I thought this 
much, that neither I, nor any other, should ever 
cauterize any wounded with giin-shot." He seems 
to have repeated the operation frequently which led 
to the suggestion to apply the ligature to" the vessels 
in amputations. After consulting with surgeons of 
Paris, it was determined to make experimental trial 
and accordingly the ligature was formallv u.sed in an 
amputation and with satisfactory results. In the 
carnpaign of 1552 Pare applied the ligature in ampu- 
tations systematically and thus it became a recognized 
method in practice. 

He was now made one of the twelve royal surgeons. 
In 1554 he was made a fellow of the College de St. 
Come in spite of the opposition of the professors of the 
University who objected that he did not understand 
Latin. He became surgeon to King Henrv II, Francis 
II, and Charles IX, and died (1.590) "highlv honored 
by his iiation, in spite of the fact that he was decried 
by the literati of his day as an ignorant upstart and 
plagiarist" (Baas). 

Par6 was an instructor and several of his pupils 
attained to high rank. He published several works 
the most important in 1504, entitled, " Dix livres de 
Chirurgie." As a practiser his operations had a wide 
range. He performed the radical operation for her- 
nia; also herniotomy in strangulated hernia; habitu- 
ally employed trusses; taught how to recognize indura- 
tion of the prostate and fracture of the neck of the 
femur; introduced the operation of staphylopla.sty ; im- 
l)roved trepanning with the crown trepan; performed 
bronchotomy; employed the ligature in the treatment 
of fistula in ano; healed wounds of the nerves; re\ived 
the figure-of-eight suture in hare-lip; was the first to 
remove loose cartilages of the joints by direct incision; 
taught version by the feet and was the first to induce 
labor artificially at full term in cases of hemorrhage. 

Fare's special service to the progress of scientific 
surgery was determining the question of the advan- 
tages of healing wounds by first intention and the 
method by which that result can most effectually be 
secured. From the time of Hippocrates this question 
had di\-ided surgeons more effectually than any other 
and especially in regard to the belief that gun-shot 
wounds, then a novelty, were necessarily poisoned. 

The discoveries of Vesalins and Par6 had a strong 
tendency to divert practical surgeons from scholastic 
teachings to natural methods. Many advances were 
made in anatomy but the number of surgeons eminent 
during the sixteenth century was comparatively few. 

Giovanni di Vigo (14()()-1519), of Rapalo, near 
Genoa, was distinguished for his work " Practica 
Copiosis" (1514), which work had a very large and 
extended influence upon the practice of surgery, pass- 
ing through fifty-two editions. He regarded gunshot 
wounds as poisoned and cauterized them with a hot 
iron, used frequently; or with boiling oil. He intro- 
duced the crown trepan and practised the ligation of 
arteries, transfixing them with needles and tjnng them 
above the ligature. 

Caspar Tagliacozzi (1546-1599\ professor of anat- 
omy and surgery in the I'niversity of Bolonga, was 
distinguished for his work in plastic .surgery, especially 
rhinoplasty. His surgical works were published in 
1597. He is reputed to have learned the art from 
the Sicilian Brancas. the elder of whom, made his 
flaps for a new nose from the skin of the face, the 
Indian method. His son used the skin of the arm 
and extended his method to the repair of mutilated 
lips and ears. Tagliacozzi laid the foundations of 
plastic surgery. 

41 



Surgcr). Uislur) of 



REFERENCE HANDBOOK OF THE MEDIC.\L SCIENCES 



Pierre Franco, born about 1500, was a native of 
Provence, Switzerland. He was the most fanjous of 
a class of itinerant surgeons called "incisors," or 
"cutters." His most important contribution to sur- 
gery was in lithotomy. He first used the old opera- 
tion called. "cuttinK on the erippe," but sub.sequently 
he performed suprapubic litliotomy, the first opera- 
tion of this kind. The patient was a child ten years 
old, in whom Franco was unable to remove the stone, 
because of its larpce size, by perineal section. He did 
not, however. adViso this operation in general prac- 
tice. In strangulated hernia, he operated without 
the removal of the testicles, as had been the practice 
until his time. 

Paracelsus (U9.3-l.')41) of Zurich, Switzerland, 
though not a practical surgeon, still exerci.sed a great 
influence upon the opinions of his day, by his caustic 
criticisms. He was the son of a physician, with whom 
he studied, devoting himself especially to alchemy and 
astrology. He was a brilliant but erratic genius, 
traveled widely, practising his profession in various 
places. His teachings had a powerful tendency to 
divert thought from scholastic to rational methods. 
The value of his writings on surgery was the substi- 
tution of the natural for the empirical system. In 
treating of the larger wounds, he says: "It is neces- 
sary to note in the first place what is the efficient cause 
in the curing nf wounds, because this may of itself 
indicate the proper treatment. Know then, that the 
human body contains in itself its own proper, radical 
balsam, born in it and with it, and not only the body 
as a whole contains it, but all its parts, such as flesh. 
bone and nerves have each its own peculiar juice com- 
petent to cure wounds. It is not the surgeon who 
cures the wound, it is the natural balsam or juice in 
the part itself." He speaks of the practice of induc- 
ing superation in woimds as the "damnable precept 
which teaches that it is necessary to make wounds 
suppurate." 

Though the sixteenth century was remarkable for 
two epochal events in surgery, no distinguished sur- 
geon appears in the records hut Par6. Nevertheless, 
it is evident that the study of the physical sciences 
became far more important than hitherto, due to the 
writings of Vesalius. 

The Circulation- of the Blood (William Harvey, 
1.578-1657). — -The distinguishing feature of the seven- 
teenth century was the discovery of the circulation of 
the blood by William Harvey, born in Folkestown, 
Kent County, England, and educated at Canterbury 
and Cambridge. In 1,599 he went to Padua to pursue 
the study of medicine in its famous school and there he 
remained a student for five years, under Fabricius ab 
Aquapendente. Upon his return to England he was 
first appointed a physician to St. Bartholomew's 
Hospital, London, 1609, and in 1615 he became jirofes- 
sor of anatomy and surgery at the College of Physi- 
cians. Subsequently he was appointed Phy.sician 
Extraordinary to James I, and an ordinary physician 
to Charles I. He was in active practice until he 
published his discovery (162S) which created such 
discredit that he was even regarded as demented 
and thereby he lost much of his business. His opin- 
ions were known prior to their publication, for he had 
taught them in his lectures in the College of Physicians 
since 1616, and already the oi)position to him was so 
great that he published the first edition of his work in a 
foreicn country, viz., at Frankfort-on-the-Maine. 
Much of his subsequent life was spent in defending his 
theory of the circulation of the blood, but he lived in 
retirement in London to his eightieth year. 

He established the fundamental facts "that the 
blood passes through the luncs and heart by the pul- 
sation of the ventricles, and is sent for distribution to 
all parts of the body, where it makes its way into the 
veins and pores of the flesh, and then flows by the veins 
from the circumference on every side to the center, 

42 



from the lesser to the greater veins, and is by them 
finally discharged into the vena cava and right auricle 
of the heart, and this in such a quantity, or in such a 
flux and reflux, thither by the arteries, hither by the 
veins, as cannot possibly be supplied by the ingesta, 
and is much greater than can be required for mere pur- 
poses of nutrition; it is absolutely necessary to con- 
clude that the blood in the animal body is impelled in 
a circle." 

"This discoverj'" says Baas "dispelled many of the 
favorite theories of the past: It overturned the 
whole physiological and philosophical foundations of 
the medicine up to that time by certain results gained 
through the inductive method." 

A recent work by the late Professor ,Iohn G. Curtis 
on "Harvey's Views on the Use of the Circulation 
of the Blood" contains a critical review of the contro- 
versies which grew out of Harvey's announcement of 
his theory of the circulation of the blood. 

Though the seventeenth century was not distin- 
guished for any remarkable apparent growth, still 
there seems to have been a steady, quiet advance in 
the study and progress of surgery. According to Baas, 
the seventeenth century ... is highly important in 
the history of the development of surgery through 
the elevation, attained in silence and accomplished 
within itself. He states that surgery now won a 
wider field for action as the Dutch, English, Germans, 
and Danes, who had up to this time attained little 
prominence, now began to distinguish themselves 
in this department; the number of surgeons known 
by their writings and discoveries is large compared 
with that of the sixteenth century. 

Among the Italians, Cesare "Magati (1579-1647) 
professor at Ferrara was regarded as the pioneer in the 
simplification of the treatment of wounds. He 
advocated infrequent dressings and instead of chang- 
ing them several times a day, as was the custom, he 
would have them renewed once in four days. This 
reform was effected by .avoiding the use of poultices, 
salves, plasters, etc., and maintaining cleanliness, by 
employing bandages wet with clean water. 

"Two names appear prominently among the German 
surgeons at this period. Fabricius Hildanus (1560- 
1624) of Hilden is often alluded to as the father of 
Gorman surgery; he was bold as an operator, being 
the first to amputate the thigh above the di-seased 
part ; employed a knife-shaped cautery in hemorrhage; 
removed a particle of iron from the cornea by means of 
a magnet. 

Purmann (164S-1721) of Luben in Silesia is held by 
Germans in the same esteem as Hildanus. Baas says: 
"he was a bold and experienced operator, knocked 
about and educated in the field, an author of a mili- 
tary surgery." He practised all the current opera- 
tions of his time; he lamented the low state of surgery 
in Germany and strongly advocated a knowledge of 
anatomy. He treated wounds of the intestines with 
the simple suture; employed bimanual examination for 
stone; used the speculum ani and yagina> in the diag- 
nosis and treatment of s\-philis. He lamented the 
low state of surgery in Germany. His writings wore 
highly esteemed. 

The supremacy which France had attained in sur- 
gery in the fifteenth and sixteenth centuries through 
its high-grade universities, was maintained in the 
seventeenth century notwithstanding the disturbances 
created by the barber surgeons. "Though no single 
surgeon reached great eminence there was an unusu- 
ally large number whose average standard of effi- 
ciency was comparatively high. 

In "England, Richard Wiseman (1622-1676) took 
rank with the ablest surgeon of the period; he was 
surgeon to King Charles I and to Charles II. He had 
a large military experience in the civil war and 
upon the continent; he was the first to describe j 

tuberculosis of the joints "tumor albus;" he was the 
first to perform external urethrotomy for stricture 



REFERENCE HANDBOOK OF THE MEDIC.\L SCIENCES 



SurgeiTi HUtory ef 



in 1562. To control hemorrhage, though familiar 
with the hgation of vessels, he preferred the use of the 
"royal styptic," but had the actual cautery in readi- 
ness for use. He is reported to have thought that 
ligation required too much light and too many assist- 
ants to be used in battles on land or sea. His chief 
work was entitled, "Several Chirurgical Treatises" 
(1672). 

Among the Dutch and the Danes surgery reached a 
high reputation during this century. 

\ noticeable feature of the seventeenth century was 
a large increase of universities in the European States, 
many of which became centers of medical education, 
such as Paris, MontpelUer, and Leyden. It was 
through these university schools, that the seventeenth 
centurj- paved the way for the greater achievements of 
the eighteenth century. Though Germany suffered 
severely from the distractions of the "Thirty Year's 
War," its close was the signal for a remarkable 
advance in devotion to the medical sciences, especially 
anatomy and physiology. 

"The seventeenth century," says Garrison," was 
the great age of specialized anatomic research, and was 
notable for a long array of individual discoveries and 
investigations, nearly everj-one of which had a physio- 
logical significance." The invention of the micro- 
scope (1610) enlarged immensely the field of anatomy 
by making \-isible hitlierto unknown structures as well 
as the elements of all structures. It is impossible to 
detail the vast number of important discoveries in 
anatomy, gross and minute, which followed Harv-ey's 
publication of his work and also the invention of the 
microscope. 

Some of the more important were as foUows: the 
discovery of the thoracic duct and receptaculum 
chyU by Pecquet (1622-1674); the pancreatic duct by 
Wirsung, in 1642; the antrum of Highmore, in 1651; 
the heart as a muscle, in 1669; the structure of the 
kidneys, by Balanni in 1662; account of the ovar\' and 
Graafian follicles in 1672; the parotid duct in 1662; 
lymphoid follicles in the small intestine in 1677. 
Harvey's discovery also led to the injection of the 
minute vessels with various substances, which resulted 
in the beautifully colored museum specimens which 
are now so useful in demonstrations of anatomy. 

The eighteenth century opened with Paris as the cen- 
ter of education. Students from all civihzed nations 
gathered in its universities. The practice of surgery- 
was along lines laid down by the French teacliers 
until the advent of John Hunter in the latter portion 
of the century. The surgeons prominent during 
the intervening period were numerous but their 
improvements of surgical practice related chiefly to 
details. 

Jean-Louis Petit (1674-1750) was the leading 
French surgeon in the early days of the eighteenth 
century. He was a director of the "Academic de 
Chirurgie;" when eighteen years of age, he entered the 
army, thereby gaining experience that ser\'ed a useful 
purpose in his future work. He was the inventor of 
the screw-tourniquet, which has come down to our 
own times; he was the pioneer in operations on the 
mastoid process and further perfected the operations 
of amputation and herniotomy. His principal works 
were his "Treatises of Surgical Diseases and Opera- 
tions." Dominique Ancl (1628-1725) of Toulouse, 
a pupil of Petit, treated traumatic aneurysm by single 
ligature (1710), thus anticipating John Hunter. 
Pierre Brasdor (1721-1776) was a di.stinguished pro- 
fessor of surgery, and advised the treatment of certain 
aneurysms by ligature on the distal side of the tumor, 
an operation afterward adopted by the English sur- 
geon Wardrop. Henri-Francois le Dran (16S.5-1770) 
was a very distinguished teacher of surgery and had 
many pupils from Germany, who made his methods of 
practice popular in that countn.-. He was sent, as 
chief surgeon, to the army 1734, and published his 
observations, which passed through several editions; 



his chief work was on operative surgcrv, published in 
1742. 

Claude Nicolas le Cat (1700-1768) of Rouen, was 
famous as a Uthotomist ; he was a Professor of anatomy 
and surgerj- in the School of Rouen; a prolific writer 
especially on Uthotomy. Pierre Joseph Desault 
(1744-1795) rose to eminence in spite of great obsta- 
cles, and -n-ithout a collegiate education became the 
chief surgeon in the Hotel Dieu; he was the first to 
estabhsh surgical cUnics and laid the foundation of 
surgical anatomy. He greatly improved the svstem of 
operations by inventing appropriate instruments; 
he was distinguished as an educator of students but 
left no writings. Frangois Chopart (1743-1795) who 
is well known for his method of amputation of the foot, 
was an intimate friend and contemporarj- of Desault. 

In Italy, the most distinguished surgeon of the pe- 
riod was .\ntonio Scarpa (1752-1832). a professor in 
the schools of Modena and Pavia. He was a distin- 
guished anatomist; he was the first to determine 
arteriosclerosis as a lesion of the inner coats of the 
arteries; he described the region known as "Scarpa's 
triangle;" he invented a shoe for club-foot, which is 
still in use, and was the first to illustrate the nerves of 
the heart. His most important works were on hernia 
and diseases of the eye. He illustrated his own work.? 
and it has been said that they "are the crown and 
flower of achievement in anatomic pen drawing" 
(Garrison). 

In Germany, Lorenz Heister (168.3-1758), was the 
first surgeon of complete scientific education (Baas). 
He studied in Amsterdam and Leyden but acquired 
his surgical experience in the Dutch military service. 
In 1710 he was called to .\ltdorf, and in 1720 he came 
to Helmstead. His principal work was "Chirurgie," 
1718. 

In England, William Cheselden (167,8-1752) was 
the leading surgeon in London, at the beginning of the 
eighteenth century. He was a native of Lcistershire 
and a student of the anatomist Cowper. In 1719 he 
became surgeon of St. Thomas' Hospital. In 1723 he 
published a treatise on the high operation, lithotomy, 
and subsequently he changed this method for the 
lateral operation which he perfected, and which was 
popular with surgeon.s. .\s an operator in lithotomy 
he was distinguished for rapidity of action, performing 
this operation in fifty-four seconds. In 1728 he pub- 
lished his new method of making an artificial pupil by 
iriodotomy with a needle. He also pubUshed a work 
on anatomy in 1713 and an atlas of osteologj- in 17.33. 

Percival Pott (1714-1788) was the most distin- 
guished surgeon of England in the middle of the cen- 
tur}\ Having himself sustained a fracture of the 
fibula he described it and its treatment minutely, 
and it is still known as "Potts' fracture." Subse- 
quently he published a number of very- instructive 
treatises on hernia, injuries of the head, fistula in ano, 
hydrocele, dislocations, and fractures; and the most 
notable of all, caries of the spinal column commonly 
called even now, " Potts' disease of the spinal column.'' 

Chas. White (1728-1813) of Manchester, introduced 
a method of reducing dislocations of the shoulder by 
extension of the arm witli the heel of the operator 
in the axilla; first excised the head of the humerus 
1768; he was the first to describe "white swelling," 
or phelgmasia alba dolens 1784. He w-as very con- 
servative. 

Phtsiologt axd P.\thologt -Applied to Scrgert 
(Jolin Hunter, 1728-1793). — The practice of surgery 
had been along established Unes with little regard to 
conser\-ation. Operating surgeons rarely showed a 
disposition to preserve function or to render the opera- 
tion useful and even ornamental as was the practice of 
rhinoplasty by Tagliacozzi. There was wanting that 
guiding principle which a knowledge of biologj-, 
physiologv and pathology imparts. This element in 
the scientific practice of surgerj- was supplied by John 

43 



Surgery, History of 



REFERENCE HANDBOOK OF THE MEDIC.\L SCIENCES 



Hunter and created in modern surgery an epoch of 
vast importance. 

Prior to the time of John Hunter pathology, the sei- 
entitio basis of surgery, was practically unknown. This 
ifjnoranoc was largely due to the fact that in all former 
times the use of the "bodies of the dead for purpo.scs of 
teaching were prevented by law, or the Church, or by 
popular prejudice. Hunter was a devoted student of 
the natural sciences and was satisfied in his .studies 
only with a knowledge of ultimate facts. His surgical 
teachings, based upon his researches in physiology and 

Sathology, laid the foundations of modern surgery. 
lunter's character was an anomaly which it is diffi- 
cult to analyze or understand. He came to London 
from his Scotland home (I74S) a rude, uncultivated 
young man, who, on being i)laced in the dissecting 
room of his brother, William Hunter, an eminent 
physician, developed an extraordinary talent for 
anatomical research. Within a year he was teaching 
anatomy and studying surgery; in 17()1 he served as 
staff surgeon in the Army and subsequently wrote a 
treatise on gun-shot wounds; established himself in 
practice in London and made a great success; became 
surgeon to St. George's Hospital, where he taught 
surgery until his death; created a museum of his own 
preparations. 13.000 in number. His field of investi- 
gation embraced every subject which came within his 
ob.servation. He studied syphilis, which he himself 
had accidentally actiuired, distinguished between hard 
and soft chancre; described phlebitis, pyemia, intus- 
susception, shock, inflammation and gun-shot wounds. 
He also studied the vital heat of animals and vege- 
tables, superfetation, smallpox, electric fishes, free 
martins, and the regeneration and transplantation of 
tissues. 

Hunter's greatest achievement as a surgeon was his 
treatment of aneurysm. The method of Antyllus of 
applying two ligatures, one above and the other below 
the aneurysm and then removing its contents by in- 
cision, was .still the approved practice. The dangers 
from this operation were: (1) Hemorrhage, owing to 
the diseased condition of the artery where it is tied close 
to the aneurysm; and (2) the suppuration of the open 
sac. Therefore, he proposed to apply the ligature 
on the proximal side higher up, where the artery was 
sound. The first operation of applying a single liga- 
ture at a greater distance from the aneurysm made a 
good recovery, and thus established an important re- 
form in the treatment of this affection (1785). The 
new operation was opposed by leading surgeons, but 
being based on sound principles, it soon a.ssumed a 
permanent position among the recognized methods. 
Though Hunter stands forth as one of the most pic- 
turesque figures in surgical history, his claim to rank 
with the most scientific surgeons who have yet ap- 
peared cannot be contested. " His permanent posi- 
tion in science," says Garrison, "is based on the fact 
that he was the founder of surgical pathology and a 
pioneer in comparative physiology and experimental 
morphology." 

The influence of Hunter's teaching was more ap- 
parent in England and its American Colony through 
the students of surgery who attended his lectures and 
practice, than on the continent. 

The nineteenth cxntury opened auspiciously for 
the development of scientifie surgery. It was not 
only the heir to the vast experience, and knowledge 
of the past; but there arose a class of surgeons from 
time to time, competent still further to utilize this 
knowledge and experience in perfecting the art. 
The more prominent surgeons of this period were as 
follows: 

In France, Dominique-Jean Larrey (1766-1842) 
a stiident of Desault, joined the Army of the Rhine, 
continuing in the service twenty-two years; he was an 
experienced operator. He was an advocate of pri- 
mary amputations and was among the first to perform 

44 



the articulation of the hip-joint; he discovered the 
contagious nature of opthalmia, or conjunctivitis, as 
he saw it in Egypt. He wTote much, the most im- 
portant work being his "Memoirs of Military Medi- 
cine." He was a favorite of Napoleon, on whose 
staff he served; this monarch left him a large amount 
of money at his death. 

Guillaumc Dupuytren (1777-1835) rose from 
poverty and became the cleverest surgeon of his time. 
Baas describes him, as "the most brilliant and for- 
tunate surgeon of our country, equally famous as 
a keen diagnostician, a bold and dexterous operator, 
a fluent and untiring clinician and teacher and an 
enlightened physiologist." 

Jacques Lisfranc (1790-1817) was an extremely 
skillful and rapid operator; invented new methods for 
articulation of the shoulder, and for amputation be- 
tween the tarsus and metatarsus. 

Joseph-Frangois Malgaignc (1806-1865) was a 
prolific writer upon surgical topics, contributing 
largely to the literature of fractures and dislocations, 
experimental surgery and operative surgery. The 
famous anatomist Bichat (1771-1802) should be 
mentioned in this connection; he was a favorite pupil 
and assistant of Desault. 

Alfred-Armand-Louis-Marie Velpeau (1795-1867), 
born a blacksmith's son, became surgeon to several 
hospitals, and professor of clinical surgery at the Paris 
Faculty (1834-1867). He was a consciencious and 
indefatigable worker, a skillful operator, and a popu- 
lar teacher; his clinics were always largely attended 
by students and distinguished surgeons from other 
countries. He is best known to the English surgeon 
by his "Operative Surgery," translated by Townsend, 
with notes by Valentine Mott. 

Of the surgeons of this period in Germany, Johann 
Friedrich Dieffenbach (1792-1847) was a profes.sor in 
Berlin, an attractive teacher and operator, and drew 
students in large numbers to the university. He 
perfected plastic operations, was the pioneer in treat- 
ing strabismus by cutting the tendons of the muscles 
of the eye, also extended the operation of tenotomy 
to many other muscles. He wrote extensively on 
operative surgery. 

Georg Friedrich Louis Stromeyer (1804-1876) of 
Hanover, was surgeon general in the army and is con- 
sidered the father of military surgery in his country. 
His special field work was operative orthopedia by the 
application of subcutaneous tenotomy to all deformi- 
ties of the body caused by the contraction of the 
muscles, especially of the lower extremities. 

To these surgeons mav be iidded the names of von 
Langenbeck (1810-1887)'; Gustav Simon (1824-1876); 
von Middeldorpf (1824-1868); Theodor Billroth 
(1829-1894); Richard von Volkmann (1830-1889); 
Friedrich von Esmarch (1823-1908); Ernst Julius 
Ourlt (182.5-1899). 

In Russia, Nikolai Ivanovich Pirogoff (1810-1881) 
took preeminence in his time. He was educated at 
Berlin and Gottingen and records his contempt for the 
lack of teaching of anatomy in these schools. In 1840 
he was appointed professor of surgery at the Medico- 
Chirurgical Academy at St. Petersburg, a position 
which he held for forty-five years. During the Cri- 
mean war, he spent fourteen months at Sebastopol, 
witnessing the devastations of hospital gangrene, 
erysipelas, and infective diseases among the soldiers. 
His severe criticisms of the inefficient management of 
the sanitary conditions were resented by the authori- 
ties, and he was forced to resign his professorship. He 
was among the first to use ether in anesthesia. He 
won distinction by his peculiar method of complete 
osteoplastic amputation of the foot. In England 
during the nineteenth century. John Abernethy 
(1764—1831) was a pupil of Hunter and the immediate 
and successful advocate of his teachings. He was 
the successor of Pott as surgeon of St. Bartholomew's 
Hospital in 1787. He began to give private lectures 



REFEREN-CE HANDBOOK OF THE MEDICAL SCIENCES 



SurgerT, History of 



on anatomy at his own house and his success was so 
great that the governors of St. Bartholomew's built 
a lecture theater, where he taught anatomy, physiol- 
ogy and surgery. He was the first to ligate the ex- 
ternal iliac (17i36) and repeated the operation four 
times, twice with success; also, ligated the common 
carotid 1796 for hemorrage; performed neurectomy 
1793, and demonstrated the union of the nerve; 
opened lumbar abscess by valvular incision to avoid 
the entrance of air. 

Sir Astley Paston Cooper (1768-1841) was also a 
student of Hunter and the most conspicuous sur- 
geon of the first quarter of the century. When twenty- 
one vears of age, he became demonstrator of anatomy 
of St. Thomas' Hospital, 1789; and in 1800 was 
appointed surgeon to Guy's Hospital. He was an 
indefatigable worker throughout his life, filling each 
day from six in the morning till midnight, with the 
service to two large hospitals, teaching cla.sscs of 
students, daily making dissections; advising crowds 
of both rich and poor at his own house, and dictating 
in his carriage for his published works; he was a most 
painstaking and successful operator; in 1808 he 
successfully ligated the common carotid and the exter- 
nal iliac arteries; 1817 he ligated the abdominal aorta. 
His work on hernia, injuries, of the joints, diseases 
of the testis, and the anatomy of the thymus gland 
were standard authorities. 

Of the surgeons of London, we can only mention 
some of the more prominent of this centurv, viz.: 
WiUiam BUzard (1743-183.5); Henry CHne" (17.50- 
1827); Benjamin CoUins Brodie (1783-1862); Ben- 
jamin Travers (178.3-1858); Robert Li.ston (1794- 
1847); Sir William Fergus.son; Sir James Paget. 

The Edinburgh Medical School had now become 
important through the labors of the Monros, father, 
son and grandson, who reigned supreme from 1725- 
1846, a period of 125 years. The elder of these was a 
pupil of Cheselden and was the first professor of 
anatomy in the University of Edinburgh; he also gave 
clinical lectures on surgery, and as a writer took rank 
as an authority. His son was a professor of surgery 
until 1810, when his son succeeded him and remained 
in this position until 1846. The elder Monro was 
the most eminent as a teacher and surgeon, and by his 
reputation gave a high character to the University 
Medical School. 

Scarcely less attractive to students was the private 
school of antatomy and surgery of John and Charles 
Bell; the former was a bold and fearless surgeon and a 
brilliant operator; while his brother Charles Bell was 
eminent as an investigator, writer and teacher, es- 
pecially of the nervous system. 

John Lizar (1783-1860) was a pupil of John Bell, 
and became professor of surgery to the College of 
Surgeons in 1831 ; he was a fellow pupil of the Ameri- 
can surgeon, McDowell; followed his lead in ovari- 
otomy 1825. James Wardrop (1782-1869) of Edin- 
burgh, settled in London in 1809; he is known for his 
successful operations in applying the ligature of the 
distal side of the aneurysm, as recommended by 
Brasdor. 

The most eminent surgeon of Edinburgh was James 
Syme (1799-1870), a very conservative operator, 
who is best known by his work on amputations and 
excisions. He was among the first surgeons to adopt 
ethor anesthesia; he was also one ofthe first to accept 
the antiseptic method of his pupil and son-in-law 
Lister. It was his practice to treat aneurysm by ligat- 
ing the artery above and below the tumor and incis- 
ing it. He is best known by his amputation at the 
ankle-joint. 

Abraham Colles (1773-1843) was among the promi- 
nent surgeons of this period in Ireland. His works on 
surgical anatomy and surgery were valuable contri- 
butions to surgical literature. But he is famous for 
his description of the carpal end of the radius, known 
as "Colles' fracture." 



The Develop.ment of Sck<;eky i.\ .\iiERicA.* — 
American surgery had its origin in the medical schools 
of London and Edinburgh. Prior to the organization 
and establishment of medical colleges in this country 
(1765-1767), the graduated surgeons took their de- 
grees from the British schools. During the succeeding 
half century the more ambitious students of surgery 
who graduated from the home schools took post- 
graduate courses of instruction in the schools and 
hospitals of the mother country. A reference to the 
teachers of the science and art of surgery in the British 
schools during this period, detailed on a former page, 
enables us to form a jiSiSt estimate of the qualifications 
of their American graduates to create a system of 
medical education in this country. 

Whatever other forces may contribute to the forma- 
tion of the special peculiarities of the practice of a pro- 
fession it is the education of its individual members 
which determines its character more largely than any 
other factor. The school formulates the principles 
which govern the future acts of its pupils, and the 
quality and value of the in.struction depend entirely 
upon the qualifications of the teachers. Mr. Erichsen, 
in his address on "Impressions of .American Surgery," 
truthfully remarks: "The method of doing things in 
surgery is transniitted directly from the master to the 
pupil; the American of a past generation acquired in 
this way the traditionary art of British surgery, and 
has transmitted it directly to his descendants. Sur- 
geons of both nations drew their inspiration from 
the same source and drank at the same fountain of 
knowledge." 

Though American surgery was originally but a 
transplanted root of British surgery to a virgin soil and 
its subsequent evolution was along lines established by 
the parent, it is not difficult to distinguish, at many 
points of contrast, that American practice has always 
been characterized by a greater freedom of thought, 
a promptness of action, and an afRucnce of resources. 
Foreign surgeons accustomed to the observance of 
technical rules of practice, have attributed the inde- 
pendent spirit of American surgeons in their methods 
of operating to ignorance of established rules and even 
to mere recklessness. But experience has proved that 
these attributes have simply illustrated the genius of 
British surgery emancipated from the thraldom with 
which the traditions of the barber surgeons had fet- 
tered the progress of scientific surgery in Europe for 
centuries. In order to have a proper understanding of 
the trend of the development of .American surgery we 
must first enquire as to the educational character of 
the medical schools, and their teachers. 

In 1765 the Medical Department of the College of 
Philadelphia was organized, chiefly through the efforts 
of Dr. John Morgan and Dr. William Shippen, Jr. 
They were natives of Philadelphia, graduates of 
literary institutions, had studied medicine in due 
course in the office of prominent physicians and com- 
pleted their profes.sional education in the British 
schools. In the scheme of instruction the promoters 
followed the European plan of giving surgery a sub- 
ordinate place in connection with other branches and 
united it with anatomy. Dr. Joseph Carson, historian 
of the Medical Department of the University of 
Pennsylvania, says: "The Medical School of Phila- 
delphia may be said to be the legitimate offspring of 
that of Edinburgh." 

Dr. Shippen though devoted to the practice of mid- 
wifery was appointed professor of anatomy and sur- 
gery, and held this position until 1S05. a period of 
forty years. It appears from the announcement of 
his lectures that the course of instruction in surgery 
was limited to "all the necessary operations of sur- 
gerj-," and "a course of bandages." Considering how 

•The writer recently had occasion to prepare a paper on "The 
Evolution of American Surncry" which contains much matter [jerti- 
nent to the present historical sketch and from which he has made very 
liberal extracts. 

45 



HurKor). Illstnr) uf 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



few operations were retjarded as necessary, and liow 
important was the use of the bandage at that time, we 
ran estimate the character of the surgical instruction 
imparte<l by Dr. Shippen. He was, however, a 
popular teacher, and by liis devotion to the duties of 
his professorship amid the distractions of the war of 
tlie Revolution and the dissensions of the profession, 
powerfully aided in preser\nng the foimdations on 
wliiih the Medical Department of the University of 
riiiiisylvaiiia, the successor of the College of Philadel- 
phia, iiad been reared. 

In the year 1805 the teaching of surgery w.is 
divorced from that of anatonW and midwifery, and 
became an independent professorship in what was now 
the Medical Department of the Universitv of Pennsyl- 
vania. Dr. Philip Syng Pliysick (170S-1.S3T) was 
appointed to the new position. He was admirably 
adapted to elevate thenewprofessor.ship to tlie highest 
grade then attainable. He was a native of Philadel- 
I)hia, of English descent and received his c()Ilegiate 
education at the I'niversity of Pennsylvania. He 
studietl medicine in the olTice of a physician and in 
17S9, at the age of twenty-one, became the private 
pui)il of John Hunter and a member of his family. 
He was apiiointed to the house staff of St. George's 
Hospital, London, through the influence of his master 
with whom he seems to liave been a favorite, for at the 
close of his residence Hunter requested him to become 
his partner. He visited Kilinburgh and received his 
degree in 1792, at the age of twenty-four. On return- 
ing to Philadelphia he began practice under favorable 
conditions; was elected surgeon of the Pennsylvania 
Hospital in 1794; gave lectures on surgery to the stu- 
dents in the University in ISOO; and in ISOS was ap- 
pointed to the new professorship of surgery created 
in the University. He held the position thirteen years, 
when he accepted the chair of anatomy, which he re- 
tained until 1830. 

Dr. Joseph Carson, the historian of the Medical 
Department of the University of Pennsylvania, thus 
speaks of Dr. Physick's method of instruction: "The 
lectures were carefully written out and delivered with 
the manuscript before him or in hand; for it was an 
axiom with him that on so important an occasion as 
the instruction of youth in an art so necessary to the 
well-being and hapi)ine.ss of mankind, every care 
should be taken to render the inculcation of principles 
and practice clear to the comprehension of students. 
His dignified bearing and imposing presence, his 
emphatic manner, and painstaking execution of his 
duties deeply impressed his pupils and commanded the 
profoundest deference." The immediate successors 
of Phvsick in the chair of surgerv in the Pennsylvania 
school— Gibson (178S-18(iO), Henry Smith (181.5- 
1890), Agnew (1818-92)— have maintained the high 
character which he gave it. 
^ In 1707, the Medical Department of King's College, 
New York, the second pioneer college, was organized. 
and on November 2, of that year the introductory ad- 
dress to the first course of lectures was given. In the 
plan of instruction in surgery adopted by the promoters 
of this school, we recognize the first "departure from 
European methods anfl the initial step in creating a 
class of distinctly .\meriean surgeons. Tlie faculty not 
only exhibited a commendable spirit of independpnce 
of the_ traditions of the i)ast, but they demonstrated 
unec|uivocaIlythat they recognized higher ideals of sur- 
gery as a science and an art than wore prevalent in 
foreign countries. Under the leadership of Dr. John 
Jones, surgery was divorced from all other branches of 
a medical education and erected into an independent 
professorship. Dr. Jones was appointed full professor 
of surgery, the first appointment of the kind in tliis 
country, and gave the first lecture on November 9, 
1707. He gave an annual cour.se of lectures until the 
college was closed by the war of the Revolution, 177,=). 

John Jones (1729-1791) was of Welsh origin. His 
grandfather, Dr. Edward Jones, was from Wales, 

46 



and came to this country in the famous ship Wel- 
come, with WiUiam Penn and his colony. He married 
a daughter of Dr. Thomas W'ynne, Speaker of the 
As.sembly of Penn's colony. His son. Dr. Evan Jones, 
settled at Jamaica, Long Island, N. Y., where John 
Jones was born in 1729. He was educated at a private 
scliool in New York, and, at the age of eighteen years, 
began the study of medicine with Dr. Thomas Cacl- 
walader, of Philadeljjhia. He visited London and 
attended the lectures of Dr. William Hunter and the 
practice of Mr. Percival Pott, in St. Bartholomew's 
Ho.spital. In 1757, he again visited France and ob- 
tained the degree of Doctor in Medicine from the 
University of Rheims. In Paris he attended the 
anatomical lectures of Petit, and received instruction 
from Le Dran and Le Cat, in Hotel Dieu. Dr. Jones 
enlisted as surgeon in the Continental Army, but soon 
retired on account of ill-health. In 17S0 he removed 
to Pliikulelphia, became surgeon to the Pennsylvania 
Hosijital, and was the professional attendant, on 
occasions, of Washington and Franklin. He died on 
June 2.3, 1791, at the age of sixty-three. 

Dr. Jones was eminently qualified to be the founder 
of a system of surgical education. The qualities of his 




1] 1 ^ ^<i/ 
Fia. 4702.— John Jones (1729-1791). 

mind fitted him to be a teacher, and his standard of 
professional qualification was ideal. He was devoted 
to surgery as a science and an art, and cultivated it 
with passionate zeal. He traveled extensively and 
availed himself of every opportunity to acquire 
knowledge. Although he made specialties of anatomy 
and surgery, his general studies took a wide range and 
his inquiries extended to the collateral sciences. He 
made warm friends of the most prominent surgeons of 
that time in the hospitals abroad, and was a favorite 
student of Pott, of .St. Bartholomew's Hospital, Lon- 
don, and of Petit and Le Dran, of Hotel Dieu, Paris. 
He attended the lectures of Dr. William Hunter and 
must have been brought into more or less intimate 
association with his brother, John Hunter, who was 
nearly the same age as Dr. Jones and had just com- 
pleted his studies, 1752. 

Dr. John B. Beck, in his "Historical Sketch" 
remarks of Dr. Jones: "He was well fitted by his edu- 
cation and his various accomplishments to become 
the instructor of others." He adds this very per- 
tinent statement; "Not merely as the skilful opera- 
tor, but as the scientific surgeon and the first teacher 
of surgery in the colonies, he justly deserves to be 
styled "The Father of American Surgery." 

The successor of Dr. Jones in King's College was Dr. 
Wright Post who was a native of Hempstead, Queens 
County, New York. He was a student of medicine in 
the office of Dr. Richard Bavley, a prominent surgeon 
of New Y'ork City. In 1784 he went to London and 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



SurKcry, History of 



became the house puijil of Mr. Sheldon, of St. George's 
Hospital, to which Hunter was surgeon. 

He became thoroughly familiar with the teachings 
of Hunter, and was undoubtedly present when that 
surgeon performed his first operation of ligating the 
femoral artery for aneurj^sm, 1785. In 1786 he 
returned to New York and gave lectures on anatomy. 
In 1792 he was appointed professor of surgery in the 
Medical Department of Columbia, formerly King's 
College. From 1796 to 1807, when the College of 
Physicians and Surgeons was organized. Dr. Post 
taught anatomy and surgery, apparently without a 
rival, in Columbia College. He was the first profes- 
sor of anatomy and surgery in the College of Physi- 
cians and Surgeons, but in 1811 the chair was divided, 
at his special solicitation, and he retained the chair of 
anatomy, teaching surgerj- only clinically. In 1813 he 
received the honorary degree of Doctor in Medicine 
from the regents of the University of New York, and 
in 1821 was elected to the office of President of the 
College of Physicians and Surgeons, a position which 
he held until 1826, when he resigned. He died in 1828, 
at the age of sixty-two. 

For upward of forty years he was a prominent figure 
in the medical schools and hospitals of New York, in 
the former giving didactic and in the latter clinical 




4703.— Wright Post (1766-182 



instruction. In his lectures he taught surgerj- as a 
true science, and in his practice he demonstrated it as 
a high art. He was also the legitimate and worthy 
successor of Dr. John Jones, being appointed to the 
chair of surgery in the reorganized Medical Depart- 
ment of Columbia College, in 1792. 

Dr. Valentine Mott, one of Dr. Post's most devoted 
pupils and eminently qualified to give a judicial 
opinion, thus characterizes Dr. Post's qualifications 
as a teacher and practitioner of surgery: "He 
was unrivalled as an anatomist, a most beautiful 
dissector, and one of the most luminous and perspicu- 
ous teachers I have ever listened to at home or abroad. 
His manners were grave and dignified; he seldom 
smiled, and never trifled with the serious and responsi- 
ble duties in which he was engaged and which no man 
ever more solemnly respected. His delivery was 
precise, slow and clear — qualities inestimable in a 
teacher — and peculiarly adapting his instructions to 
the advancement of the junior portion of the class. 
As an operator he was careful, slow and elegant, and 
competent to any emergency contemplated by the 
then existing state of surgical science." 

In 1811, the College of Phj-sicians and Surgeons, 
the successor of the Medical Department of Columbia 
University, restored surgery to the position of an inde- 
pendent professorship, wliich was assigned to it in 1767, 
and Dr. Valentine Mott was appointed to the chair. 
He was born at Glencove. Long Island, .August 20, 17S.i. 
His father. Dr. Henry Mott, a native of Hempstead, 



Long Island, was the son of Adam Mott, an English- 
man and disciple of George Fox, the founder of the sect 
of Friends. At the age of nineteen he entered the office 
of his relative. Dr. Valentine Seaman, a prominent sur- 
geon of the New York Hospital. Young Mott re- 
mained with Dr. Seaman from 1H04 until 1807, when he 
graduated from the Medical Department of Columbia 
College, in which Dr. Wright Post was the professor of 
anatomy and surgerj-. Soon after graduation he 
visited London, and became the pupil of Sir Astley 
Cooepr, then the foremost surgeon of that city. He re- 
mained in London two j-ears, assisting Cooper in his 
operations and then visited the Edinburgh school. On 
returning to New York in 1809, he delivered a course of 
lectures and demonstrations on operative surgerj- in the 
anatomical rooms of Columbia College. To the.se lec- 
t ures he attributed his appointment to the professorship 
of surgery in Columbia College, 181 1, which iminediatey 
followed. This appointment was actually made on 
the advice of his preceptor. Dr. Wright Post. He 
continued in this position until 1826, when the pro- 
fessors resigned in a bodj- on account of differences 
with the regents. The Rutgers Medical College was 
then organized, and Dr. Mott entered the facultj- as 
])rofessor of surgerj-. This school continued but 
five jears. Dr. iVIott was next appointed professor 
of operative surgerj- and surgical anatomj- in the 
College of Phj-sicians and Surgeons, a position which 
he resigned in 1834, on account of failing health. He 
now traveled extensivelv in Europe, Asia, and .\friea. 
On his return he united in the effort to establish the 
Medical Department of the University of New York, 
and in 1840 was appointed the professor of surgery. 
Though the school had a verj- able facultv, the fame 
of Dr. Mott was its greatest attraction to students, 
and its classes soon far exceeded anj- hitherto gathered 
in this citj-. In 1850 he resigned this position and 
again visited Europe. On his return he was appointed 
emeritus professor of operative surgerj- and surgical 
anatomj- in the College of Phj-sicians and Surgeons, 
and commenced his course, November 7. 1850, with 
an address on "Reminiscences of Medical Teaching 
and Teachers in New York," an interesting review of 
the progress of surgerj- in this citj- for half a centurj-. 
In 18.52 he accepted the position of emeritus pro- 
fessor of surgerv in the ^Iedical Department of the 
Universitj- of New York, which he held until his 
death, giving annual courses of lectures, chiefly clin- 
ical. He died after a short illness from embolism 
affecting the right leg, April 26, 1865, his last words 
being, "Order, truth, punctuality." 

The qualifications of Dr. Mott as an educator were 
of the highest order. He was a careful and accurate 
student of the medical and collateral sciences, and 
based his practice of surgerv upon the principles 
which thej- inculcated. He had been trained nt home 
in the school of Hunter by his preceptor. Dr. Wright 
Post, and abroad by Home, .\bernethy. and Cooper. 
He was the legitimate successor of Dr. John Jones and 
Dr. Wright Post in laying broad and deep the founda- 
tions of surgical education, not only in the schools of 
New York, but in the colleges of the country organized 
bv graduates of these metropolitan schools. 

"Alexander Hodgden Stevens (1789-1869) was a 
native of New York Citj-. He was a graduate of Yale 
College in 1807, and of the Medical Department of the 
University of Pennsjlvania in 1811. In 1S14 he was 
appointed professor of surgerj- in the New York 
Medical Institute, and in 1818 he became one of the 
visiting surgeons to the New York Hospital. In 1826 
he was appointed professor of surgery in the College 
of Physicians and Surgeons, as the successor of Mott. 
He retired in 1838 on account of failing health, and 
was made emeritus bv the board of regents. He died 
in 1869. 

The true successor of Stevens was Dr. 'V\ illard 
Parker, though the chair of surgerj- was occupied for 
two sessions by Dr. .\lban G. Smith, of Kentucky. 

47 



Surccryi History of 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



Piirker became the professor of surgery in 1840, having 
been called from the Cincinnati College, Ohio. He 
was a graduate of the Harvard Medical College and a 
private i)upil of Dr. John C. Warren. Thus it hap- 
pened that the chair of surgery, one occupied by 
Jones and Post, then made illustrious by Mott, one of 
its own pupils, next tilled by a rejireseiitative of 
Phvsick, was now to be given to a student of \Varren. 
Parker had many of the (jualifications of the best 
class of teachers. "His very presence and personality 
commanded the confidence, respect, and even admira- 
tion of students. His mental attributes and his tem- 
perament rendered his teaching practical rather than 
theoretical and speculative. He readily grasped the 
essential facts of any subject matter, and at once 
endeavored to estimate their practical value. This 
peculiarity of his teaching was attractive to students 
and practitioners, and always gave him large and 
attentive audiences. His special characteristics as a 
teacher of surgery were seen to the best advantage in 
the clinics which he organized in the lecture-room of the 
college, the first of the kind in this country. Here, 
in a familiar manner, he illustrated the diagnosis and 
treatment of surgical diseases and applied the princi- 
ples which he taught to practice. 




Fig. 4701.— John Warren (1753-1815). 

WUlard Parker (1800-1884) was a native of Hills- 
boro, N. H. He graduated from Harvard College in 
1826. He was a pupil of Dr. John C. Warren, and 
served one year as house surgeon in the Massachusetts 
General IIos|)ital. He graduated in medicine from 
the Harvard Medical School in ISUO, and soon after 
accepted tlie profcssorsliip of unatomv in the Berkshire 
Medical College at Pittsfield, Mass. In 1832 he 
delivered a course of lectures on surgery in the same 
institution. In 1836 he was appointed professor of 
surgery in the Cincinnati Medical College, and in 1S39 
accepted the professor-ship of surgery in the College 
of Physicians and Surgeons of New York, a position he 
held thirty years. On retiring he was appointed 
emeritus professor and continued in that relation to 
the college until his death in 1884. 

.\t the close of the Revolutionary war the third 
pioneer medical school was organized. This was the 
NIedical Department of Harvard College, Cambridge, 
Mass., established in 1783. Dr. John Warren, who 
was the chief ])romotor of the school was a native of 
Roxbury. Mass. He was a younger brother of Gen. 
Joseph Warren, a surgeon, who fell at the battle of 
Bunker Hill, June 17, 1776. He was educated at 
Harvard College, which he entered at the age of 
fourteen. He then began the study of medicine with 
his brother, and on receiving his degree he located in 
Salem at the age of twenty years. Like his elder 

48 



brother, Joseph, Dr. John Warren was an ardent 
patriot, and joined Colonel Pickering's regiment as a 
volunteer, and marched to the defence of the military 
stores at Concord. He was present at the first battle 
at Lexington. He was afterward attached to the main 
army under the immediate command of General Wash- 
ington. He was at many important battles, as that 
on Long Island, at Princeton, and his services were 
highly appreciated by the Commander-in-Chief. 
After suffering a severe attack of fever, he was as- 
signed to duty at Boston, where he remained until the 
close of the war. In 1780 Dr. Warren gave a coiirse 
of lectures with dissections at the Military Hospital 
and the following year the students of Harvard College 
were permitted to attend. These lectures led to the 
creation in 1783 of the Medical Department of Har- 
vard College. 

Dr. Warren oecupied the chair of anatomy and 
surgery upward of thirty years. He died April 3, 
181.5. Dr. Thacher, a pupil of Dr. Warren, thus de- 
scribes his personal appearance: "He was of about 
middling stature and well formed ; his deportment was 
agreeable; his manners, formed in a military school 
and polished by intercourse with the officers of the 
French army, were those of an accomplished gentle- 
man. An elevated forehead, black eyes, aquiline 




Fig. 4705.— J. C. Warren (1778-1856). 

no-se, and h.air turned up from his forehead gave him an 
air of dignity which became a person of his profession 
and character." 

Dr. John Collins W'arren (177S-1856) became the 
assistant of his father. Dr. John Warren, the founder 
of the Harvard School. In 1806 he was associated 
with his father in the chair of anatomy and surgery, 
and on the death of the Latter in 181.5 he became full 
professor, and continued in that position until 1847, 
when a professorship of surgery was created, and he 
became the emeritus professor. He died May 4, 
1856. 

The successor to Warren in the Harvard school, in 
1847, was Dr. George Hayward (1791-1863). He was 
a native of Boston, a graduate of Harvard College in 
1809, but he graduated in medicine from the Univer- 
sity of Pennsylvania in 1812. As a teacher, it is 
stated, "thoroughly versed in the principles and 
theory of surgery, he was a remarkably practical and 
popular teacher in the professor's chair and at hos- 
pital clinics." He died in 1863. 

In 1849 Dr. Henry J. Bigelow succeeded Hayward 
as professor of surgery in the Harvard school, and con- 
tinued in that position until 1882, a period of thirty- 
three years. Bigelow was qualified by birth, mental 
endowments, and preparatory training, not only to 
maintain the high standard of educational qualifica,- 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



tions which the Harvard school required of its gradu- 
ates, but to adv-auce that standard so that it kept pace 
with the rapid development of the medical sciences 
during the period of his service. It is well stated of 
him that as "inventor and discoverer by nature, his 
constant aim was to enlarge the boundaries of his 
profession, and to this end his fertility in ideas and 
remarkable mechanical ingenuity came to his aid." 
He was preeminently a master of both the science and 
the art of surgery, and in his teachings he was able so 
to combine principles and practice that the student 
became proficient in both branches of the subject. 
The fourth pioneer medical school, perhaps more 
than the preceding, illustrates the genius of American 
surgery, viz., its independent spirit. In the year 
1798 the Medical Department of Dartmouth College, 
at Hanover, N. H., was established, at the suggestion 
of Dr. Nathan Smith, a graduate of Harvard Medical 
College. The most interesting feature in the organi- 
zation of this school was the composition of the faculty, 
which consisted of a single person, viz., its promoter. 
Dr. Nathan Smith. For twelve years he gave full 
courses of lectures on all of the different branches of 
medicine then taught, except two courses in the de- 
partment of chemistry. 




Fig. 4706 —Henry Jac b I! „cIow (ISIS 1890). 

Nathan Smith was born at Rehoboth, Mass., 
September 30, 1762. His education was obtained at 
the public school. At the age of twenty-four he wit- 
nessed a surgical operation, which so impressed him 
that he determined to study medicine, and accordingly 
applied to the surgeon to be admitted to his office as a 
student. He was directed to prepare himself for 
admission to Harvard College before commencing the 
study of medicine, which he promptly did, and was 
then allowed to enter and register as a student. After 
three years of study he located in practice at Cornish, 
Vt. Soon after, he attended the lectures on medicine 
and collateral sciences at Harvard College, from which 
he received the degree of Bachelor of Medicine in 
1790. He returned to his practice, which he pursued 
with marked success for five or six years. During 
this time he became much impressed with the low 
grade of educational ciualifications of the practitioners 
with whom he was brought in contact. On this ac- 
count his biographer states that "he was led to pro- 
ject a medical institution in connection with Dart- 
mouth College, in order to rear up for the widespread 
regions of the interior of New England a race of better 
educated, more enlightened, and more skilful physi- 
cians and surgeons." His plans being approved by the 
president of the college, Dr. Smith sought to better 
qualify himself for the new duties by attending the 
schools of London and P>linburgh. He returned in 
September, 1797, and early in the year 1798 began a 
course of lectures which embraced the entire circle of 

Vol. VIII.— 4 



.Surgery, History of 



the medical sciences, as then understood, and which 
he repeated for twelve successive years. 

In 181.3 he was invited to the cliair of "physics and 
surgery" in the recently established Medical Depart- 
ment of Yale College, which he accepted. He subse- 
quently gave one course in Dartmouth College, one 
in Vermont University, and five in the Medical Institu- 
tion of Bowdoin College at Brunswick, Maine. He 
died January 26, 1829, in the sixty-seventh year of 
his age. 

"As an instructor," saj's Prof. Knight, "the repu- 
tation of Dr. Smith was high, from the time he began 
the business of instruction. . . . That for many years 
he gave instruction upon all the branches of medical 
and surgical science, that this instruction was to cla.sscs 
of intelhgent young men, and that many who were thus 
instructed have become eminent in their i)rofossion, 
prove not only versatility of talent, but variety and 
extent of information, with a happy niethori of com- 
municating it. . . . He sought no aid from an artificial 
style, but merely poured forth, in the plain language 
of conversation, the treasures of his wisdom and 
experience." 

Of the influence of Dr. Smith upon the profession of 
New England, Prof. Knight remarks: "His influence 




4707.— Nathan Smith (1762-1829). 



over medical literature was equally extensive. This 
influence was exerted, through his Large acquaintance 
among medical men, by his advice and examiile. as well 
as more directly through the medium of the various 
medical schools which were favored with his in- 
structions. By means of his influence thus exerted, he 
effected, over "a large extent of country, a great and 
salutary change in the medical profession. The 
assertion that he has done more for the improvement 
of physics and surgery in New England than any other 
man mil bv no one be deemed invidious." 

In 1826, "Jefferson Medical College, of Philadelphia, 
was founded by Dr. deorge McClellan (179l)-;1847), 
a graduate of the Medical Department of tlie Univer- 
sity of Pennsylvania. McClellan wjis a type of the 
aspiring and aggressive young surgeons of that early 
period. He had been a pupil of Dorsey, the .assistant 
of Physick, a brilliant lecturer and accredited author. 
Soon after his graduation McClellan began teaching 
anatomy and surgery, and his vivacity of manner and 
fluency "of speech attracted large cla.<ses. It is stated 
th.at as a public teacher his style was purely extempora- 
neous; he became so absorbed with his subject as to 
be unconscious of those around him. His lectures 
achieved a popularity and produced an effect seldom 
equalled. As a practical surgeon he took rank with 
the most successful practitioners of that day. The 
school which he founded has been one of the largest 
contributers to the ranks of eminent practical surgeons 
and teachers. 

49 



SurKvr). Bl.story of 



REFERENCE HANDHOOK OF THE MEDICAL SCIENCES 



One of the most illustrious surgeons and educators 
of our period was a private pupil of McClcllun. a 
graduate of the Jefferson Medical College, and his 
successor to the chair of surgery — Dr. Samuel D. 
Gross. It is impossible to estimate the vast influence 
of Gross upon the diaractcr of surgical practice during 
his long career of over half a century, and in the three- 
fold capacity of an original investigator, a popular 
teacher in many schools, and an accepted authority on 
general surgery. He was born near Easton, Pa., 
July S, 1S05. He wjus a pujiil of Dr. George Mc- 
Clellan graduating in medicine from Jefferson Medical 
College in 1828. He located in Philadelphia, and in 
1830 published a work on "Diseases and Injuries <if 
the Bones and Joints." In 1833 he became demon- 
strator of anatomy in the Medical College of Ohio , and 
in 183.5 he was appointed professor of pathological 
anatomy in the .Medical Department of the Cincinnati 
College." His lectures were the first delivered in this 
country on that subject, and resulted in tlie prepara- 
tion of a work on the "Elements of Pathological 
Anatomy," the first work of the kind in the English 
language. In 1839 he became professor of surgery in 
the University of Louisville, Ky., and in 1850 he was 




-Samuel David G 



appointed to the same position in the Medical Depart- 
ment of the University of the City of New York. He 
gave but a single course of lectures in New York, and 
returned to his former position in the Louisville school. 
In 1805 he was appointed professor of surgery in the 
Jefferson Medical College, Philadelphia, from which 
he retired in 1882. The crowning art of his surgical 
career was the publication of his great "System of 
Surgery" in 1857. He died in 1884. 

In 1837, Rush Medical College, of Chicago, was 
founded by Dr. Daniel Brainard. This was the 
pioneer medical school in the Northwest, and has 
always maintained a high grade of surgical instruction. 

The pioneer teacher of surgery in the extreme South 
was Dr. Warren Stone, of New Orleans (1808-1872). 
He was a native of Vermont and studied medicine 
under Dr. .\mos Twitehell, one of the most famous 
surgeons of that day in this country. He took his 
medical degree in Philadelphia in 1825, and located in 
New Orleans. He was connected with the Medical 
Department of the University of Louisiana from its 
organization in 183-1. In 183G he was appointed a 
lecturer in anatomy, and in 1839 anatomy was sepa- 
rated from surgery, and he assumed the full duties of 
the chair of surgery; and for upward of a third of a 
century he taught large classes of students and exer- 
cised a great influence upon the practice of surgery. 

One of the most conspicuous surgeons of the South, 
who at an early period took an active part as a teacher 
in the newly organized medical schools, was Dr. Paul 
F. Eve. He was a native of Georgia, a graduate of 
the University Medical College of Philadelphia, and 

50 



later an attendant upon the lectures and practice of 
the leading surgeons of London and Paris. He began 
teaching in 1832, in a small college in Georgia, and 
from that time until his death he was engaged in giv- 
ing courses of lectures on surgery in a large number of 
colleges. On his final settlement in Nashville, Tenn., 
he became eminent as a practical surgeon. As an 
instructor he was popular and had flattering offers of 
professorships of surgery in the older colleges. 

This brings our narrative of the pioneer medical 
schools to the close of what may be called "the forma- 
tive" ijcriod of .American surgery. They laid the 
foundations on which its future character would be 
constructed and during the century which has since 
elapsed they have had master builders on those foun- 
dations, and to-day they take rank among the world's 
best institutions for a high-grade surgical education. 
Not less illustrious in the annals of surgery are the 
names of many of the graduates who went forth from 
these schools inspired by the highest ideals of profes- 
sional character and animated by the adventurous 
spirit which pervaded all ranks of our young communi- 
ties, to establish other schools to meet the necessities 
of the rapidly increasing, or remote centers of popula- 




FlG. 4709. — Daniel Brainard .(1812-1S66). 

tion. It is true that at the beginning many of these 
schools were wanting in necessary equipment owing to 
their isolation and poverty, but the proinotors, like 
Dr. Nathan Smith in establishing the Dartmoutli 
Medical College, were so profoundly impressed with 
the ab.sence of even the elements of a medical educa- 
tion of the ordinary practitioners for want of oppor- 
tunity that they were impelled to this missionary 
work. It is gratifying to be able in these latter days 
to record the fact that these pioneer schools — Penn- 
sylvania, Columbia, Harvard — have recently received 
endowments which will enable each to place it? teach- 
ing service in every department on the broadest and 
most efficient basis. More recently the Medical 
Department of the Chicago University (formerly 
Rush Medical College) has received an endowment of 
several millions of dollars which allies it with the 
pioneer colleges as a future great center of medical 
education of the highest order. 

Prior to the year 1800, the four pioneer medical 
colleges had graduated too few students to exert any 
marked influence upon the profession at large, espe- 
cially in regard to the practice of surgery. But during 
the first quarter of the nineteenth century the number 
of medical colleges rapidly increased and the grade of 
teaching improved. The result appears in the 
increased activity of surgeons in performing formid- 
able operations and the independence which charac- 
terized their departure from rules established by the 
foreign schools. It is during this period that we begin 
to trace the line of cleavage between .American and 



REFERENX'E HANDBOOK OF THE MEDICAL SCIENCES 



SnrgenTi History of 



European surgery, and from this time we more and 
more frequently meet the word "American" in sur- 
gical literature, in connection with new inventions and 
methods of operation. It was, therefore, during the 
early years of the nineteenth century that the evolu- 
tion of what may be termed "the American practice 
of surgery" began to appear, and it is from that period 
that we shall begin to trace its development and illus- 
trate its distinctive features. We can select only 
some of the more important c|uestions then under dis- 
cussion by British surgeons and consider their treat- 
ment by American surgeons. This examination will 
not only illustrate the special features of the American 
practice of surgery but will exhibit the achievements of 
individual surgeons. 

The. Irenlmcnt of aneurysm was a subject of absorbing 
interest to British surgeons at the close of the eight- 
eenth century. Hunter had perfected .Vnel's method 
of ligating the artery on the proximal side of the 
tumor, and had established the following principles: 
(1) The ligature should be applied at a sufficient dis- 
tance from the tumor to insure a healthy condition of 
the artery. (2) The artery should not be disturbed 
more than is necessarj' to secure the passage of the 
ligature. (3) One ligature is sufficient. (4) The 
wound should be healed by first intention. 

Hunter's operation was performed with indifferent 
success by British surgeons, according to Home, owing 
to modifications which they made of the procedure of 
the original operator. The surgeons of the continent 
ignored this method of treating aneurysm, chiefly 
because it had a British origin. But there was present 
at Hunter's first operation a young ,\merican surgeon 
from the city of New York, who thoroughly compre- 
hended the opinions of the operator, and appreciated 
at its full value the immense importance of the opera- 
tion. Dr. Wright Post was a pupil of a member of the 
staff of St. George's Hospital at the date of Hunter's 
first operation, which was performed in that hospital 
in December, 1785. Post returned to New York in 
1786, and soon took a high rank as a teacher of anat- 
omy and surgery. The treatment of aneurj'sm by 
the new operation was evidently the theme of some of 
his lectures, for Mott, his most eminent student, says 
Post expressed the opinion that not only one carotid 
artery might be ligated for aneurysm safely, but that 
both might be interrupted b_v ligature on the same per- 
son without harm, long before Astley Cooper operated 
on that artery. 

Post's first operation was the ligation of the 
femoral artery for aneurysm, in 1796. The aneurj'sm 
was caused by a wound of the artery fifteen years 
previously. The precise location of the aneurysm 
is not given, nor the point at which the ligature 
was applied. The patient recovered in the usual 
time and the tumor gradually diminished until it was 
reduced to a size not exceeding one inch in diameter. 
An interesting feature of the case was a continuance of 
the pulsation of the tumor, which Post attributed to 
the increased size of the anastomosing vessels due to 
the long continuance of the aneurysm. The limb 
became as useful as it was before the accident. This 
was the first operation for the cure of aneurj-sm on the 
Hunterian principle in this countrj', and the beginning 
of the operator's career as the practical exponent of 
the Hunterian method of treating aneurysm. 

The first operation of ligating the common carotid 
for aneurj-sm in this country was performed by Post, 
January 9, 1813. The tumor was situated below 
the angle of the jaw on the right side, and measured six 
inches in length, four inches in breadth, and two inches 
in height. Two ligatures were applied and the artery 
was divided between them. The case did well and 
was discharged at the end of four months. The pa- 
tient returned in two months, the tumor being large 
and fluctuating. It soon after opened and there was a 
hemorrhage of thirty ounces. It opened in another 
place and discharged pus and blood; severe hemor- 



rhage occurred several times and once the patient is 
thought to have lost two quarts. Extensive sup- 
|)uration de\eloped at the seat of the aneurysm but 
the patient finally recovered. 

The peculiarities of this operation were: (1) The 
passage of two ligatures around the artery about three- 
quarters of an inch apart; (2) the passage of the liga- 
ture through the artery to prevent its slipping from 
the cut end of the artery, a-s recommended by Dionis 
and Cline; and (3) the di\»ision of the artery between 
the ligatures. The danger of hemorrhage from the 
slipping of the ligature from the cut end of an artery 
was at that time regarded as very great, anrl to prevent 
it the needle was placed on the ligature after it was 
tied, and the threafl was pa.ssed through the artery 
close to the ligature and tied with the knot already 
made. 

One year later, January 4, 1814, Po.st applied a 
ligature to the external iliac for inguinal aneurysm. 
It was the second operation on the artery in this coim- 
try, Dorsey, of Philadelphia, having operated in 1811 
successfully. The important feature in Post's case 
was the necessity of opening the peritoneal ca\nty to 
reach the artery, and the recovery of the patient. 

On November 28, 1816, Post again ligated the com- 
mon carotid artery for a pulsating tumor of the neck. 
The patient recovered from the operation, but died two 
years later, and the autop.sy disclosed a tumor with no 
indications of a previous aneurysm. It was to this c.ise 
that Mott often alluded in his lectures, illu.strating 
the difficulties of correctly diagnosing an aneury.sm 
from an abscess or solid tumor overlying an artery. 
At the consultation Post diagnosed the tvimor as an 
aneurysm, Stevens as an abscess, and Mott as a solid 
tumor; Stevens suggested to Post the propriety of 
exploring it by puncture, whereupon Post responded 
by handing Stevens a lanc(-t. Stevens declined by 
passing the lancet to Mott. who refused to receive it, 
and Post was allowed to exercise his discretion. 

Post's last and most notable pioneer work wa.s the 
ligation of the left subclavian, in its third part, for 
aneurysm of the brachial artery. This was the 
eighth recorded ligation of the subclavian arter>-, the 
third which recovered, and the first in this coimtry by 
the new method. The most interesting feature of the 
case was the rupture of the aneurysm and the dis- 
charge of its contents during convalescence, with the 
final complete recoverj"- of the p.atient. 

It apjiears that Dr. Post, previous to the year 1816, 
had applied the ligature successfully to five different 
arteries, and twice to the carotid. His success has not 
been excelled, if we consider the complications he en- 
countered, in any period anterior to antisep.sis. The 
secret of his success, .aside from his great skill as an 
operator, is found in the extreme cleanliness, not only 
of his person, but of his instruments and the wound 
and dressings, thus securing a.sepsis. In a case of 
opening the peritoneum, he followed the operation 
with "an active cathartic, composed of an infusion of 
senna, manna, and cream of tartar, which caused fre- 
quent and copious discharges" — a form of treatment 
which some distinguished oper.ators have latterly 
ado[)ted as .a preventive of peritonitis. 

Brilliant as h.ad been the career of Post in his pioneer 
work of introducing the new method of treating aneu- 
rj-sm into American practice, Mott, his pupil, was 
destined to excel him in the number, variety, and 
severitv of operations, and in the perfection and pre- 
cision of details. He had a genius for scientific opera- 
tive surgery. Nothing was done hajihazard. Every 
detail, however, minute and apparently unimportant, 
was carefullv studied, and provision w.as made to meet 
everj- possible accident. He was by habit and train- 
ing an aseptic surgeon. 

Mott's pioneer work began with the ligature of the 
arteria innominata. This wtis not only his greatest 
achievement in operative surgery, but it was the most 
brilliant operation ever undertaken by any surgeon in 

51 



SurKcry, Hlstor)' of 



REFERENCE HANDBOOK OF THE MEDIC.U, SCIENCES 



the history of operative surgery to that date. Nor has 
it ever been excelled in tliis department of surgery, if 
we give due weight to all of the eircunistanees attend- 
ing the operation. It was by no means suddenly eon- 
ceived and executed as an emergency operation, but 
was the ripe fruit of years of study and preiiaralion. 
He states that "since the publication of Allan Burns' 
invaluable work on the surgical anatomy of the head 
and neck, I have been in the habit of showing, in my 
surgical lectures, the practicablity of securing, in a 
ligature, the arteria innominata; and I have had no 
hesitation in remarking that it was my opinion tliat 
this artery might be taken up for .some condition of 
aneurysms, and that a surgeon with a steady hand and 
a correct knowledge of the parts would be justified in 
doing it." The proper case ])resonted itself .March 1, 
1818, and he says: " I could not for a moment hesitate 
in recommending and performing the oiioration." 
Though the operation failed after giving the most 
encouraging prospect of success, Mott was not dis- 
heartened, but regarded its practicability and pro- 
priety as satisfactorily established by this case, and 
predicted that it would prove to be "the bearer of a 
message to surgery, containing new and important 
results." 

The arteria innominata was repeatedly ligatured 
subsequently, and it was reserved for an .Vnierican 
surgeon to .secure the first successful result. The opera- 
tor was Dr. A. W. Smj^th, of New Orleans. The 
operation was performed in 1864. In this case the 
carotid was ligated at the same time, and on the fifty- 
fourth day the vertebral was also ligated. 

Scarcely less memorable than Mott's operation on 
the arteria innomin.ata, and creditable as a great sur- 
gical achievement, was Dr. J. Kearney Rodgers' liga- 
tion of the left subclavian, within the scaleni muscles. 
The oper.ation w.as performed on October 14, 1845. 
It is an interesting fact that Mott was one of the con- 
sultants and opposed the operation, though he ad- 
mitted that it might possibly "be tied by a careful and 
well-informed surgeon," yet he "considered that it w.as 
improper to do so." CoUes, of Dublin, who was the 
first to lig.ate the right subclavian in its first part, con- 
demned a similar operation on the left, .stating that 
there was "such a combination of difficulties as must 
deter the most enterprising surgeon from vmdertaking 
this operation on the left side." The operation proved 
to be, in every respect, as difficult as had been alleged, 
but he was fully prepared for every emergency. The 
ligature was successfully applied, and for several days 
everything promised success; but the thirteenth day 
a hemorrhage occurred, which was repeated, and the 
patient died on the fifteenth day. 

Mott was the first surgeon who ligated the primitive 
iliac for aneurysm. The operation was performed on 
March 15, 1827, and was executed with his u.sual care 
and attention to all of the details. The size of the 
tumor and the adhesions of the peritoneum rendered 
the procedure very difficult, but the operator was re- 
warded with the recovery of his patient, who was liv- 
ing thirty years after. 

The experience of Mott in the ligation of arteries was 
very great and his success far exceeded that of any 
contemporary surgeon. According to his own state- 
ment, he ligated the arteria innominata once, unsuc- 
cessfully; the common iliac once, successfully; the sub- 
clavian artery in its third part six times, all the cases 
were successful; the common carotid thirty-two times, 
■with but five failures; the external iliac six times, with 
two failures (one patient died of drunkenness); the 
femoral fifty-three times, the failures being unknown. 
He had but one case of mortification of the extremity 
after ligature of an artery. 

Absorbable animal ligatures were introduced into 
practice by American surgeons, viz., Physick, Dorsey, 
and Jameson. 

Gratifying as was the .success of .Vmerican surgeons 
in their pioneer work in the ligature of arteries, and 

52 



accurate as was the technique of the operation which 
they had devised, there was .still a fatal defect which 
was to be remedied, viz., hemorrhage on the sejiaration 
of the ligature. The practice of applying a silk liga- 
ture so tightly as to divide the inner coat of the artery, 
for the purpose of securing the union of the ruptured 
surfaces, was the rule with surgeons. The result was 
the gradual division of theartcry by aprocessof ulcera- 
tion due to the irritation of the unabsorbable ligature, 
and if union had not taken place, as too often hap- 
pened, hemorrh.age w.as the result. Physick, trained 
in the school of Hunter, suggested the remedy for this 
evil, viz., the use of "dissoluble" ligatures, the pres- 
sure of t he internal surfaces of the artery together with- 
out injuring its coats, and healing the wound by first 
intention. .\t his suggestion, and under his direc- 
tions, a series of experiments were performed with 
animal material, and French kid, which was absorbed 
after several days without injury to the artery, was 
selected, as described by Dorsey, his assistant. 

A very important contribution to the subject of 
animal ligatures was made in 1827 by Dr. Horatio 
Gates Jameson (1778-1855) of Baltimore, Md., in a 
prize essay, entitled, "Observations upon Traumatic 
Hemorrhage, Illustrated by Experiments upon Living 
.Animals." Jameson's conclusions were as follows: 
(1) If an artery is sufficiently healthy to admit of its 
obliteration by adhesion of its sides, it is best done by 
a ligature which will neither cut its coats nor strangu- 
late, except in parts, the true vasa vasorum, so that 
the continuity of the vessel shall not be destroyed, 
although we obliterate its caliber. (2) If an animal 
ligature of the proper kind be properly applied, the 
vessel will be obliterated, the wound may be healed by 
the first intention, and the ligature will not cause 
suppurative inflammation, but in due time, being 
dissoluble, the whole will be removed by the absor- 
bents; there will be no breach of continuity in the 
artery. . . . The vessel, which during the state of in- 
flammation and effusion of lymph was converted into 
a cord, will pretty soon afterward be resolved into a 
flat string of white cellular structure. The experi- 
ments of Dorsey and Jameson brought the operation 
of ligating arteries to scientific perfection by prevent- 
ing secondary hemorrhage and securing healing of the 
wound by first intention. 

.\n important feature of Jameson's experiments, to 
which he seems to have attached little value, was the 
discovery that, as the animal ligature underwent ab- 
sorption, it became "completely enveloped in a .strong 
membranous capsule. . . . This arrangement of 
the capsule seemed to have the effect of drawing the 
button-like knobs (ends of the ligature, in the state of 
yellow pulp) together, and was thus closing the vessel. 
. . . The capsule covering the knobs or ends of the 
string was fully equal in strength to the outer coat of 
the artery, and therefore there was no tendency to 
hemorrhage." In the demonstration of this encircling 
ring or capsule which forms when animal ligature is 
employed for ligature, Jameson anticipated Lister, 
who describes it in his experiment as a ring of new 
tissue enveloping the dissolving animal ligature. He 
regarded it as of great import.ance in the prevention 
of hemorrhage. It certainly strengthens the artery at 
the point of ligature, where the artery has been ren- 
dered very weak by the strangulation of nutrient 
ves.sels. It is in effect like the provisional callus 
which forms at the seat of fracture of a bone — 
a temporary means of protecting a weak point in the 
vessel until repair takes place. Jameson anticipated 
Lister's experiment by more than half a century. He 
not only demonstrated at that early period the true 
method of procedure to secure success in the ligature 
of arteries by experiments on animals, but by a large 
series of operations in practice, as in ligating the 
carotid, the iliac, the femoral, the radial, and other 
arteries. 

It has not been our purpose to notice the achieve- 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



Surgery, History of 



ments of individual surgeons except as they have 
resulted in important reforms in practice. Biit there 
have been instances wliere surgeons have performed 
acts or adopted methods to meet conditions hitherto 
unknown to them, whicli illustrate American ingenuity 
and enterprise. Several of these examples deserve 
notice. 

Ampulalion at the shouldeT-joint was introduced into 
practice during the eighteenth century by French 
surgeons. The first 0|)erati(in in this country was per- 
formed by Dr. John Warren, of Boston, as early as 
1781. Dr. Warren had had a large experience in 
operative surgery during the Revolutionary War. 
The operation was performed in the Military Hospital 
at Boston and was successful. 

Previous to the year 1806, amputation at the hip- 
joint had been performed but once by British surgeons, 
and in that case the operation resulted fatally. In 
that year Dr. Walter Brashear (1776-1809), of Ken- 
tucky, performed this amputation successfully. The 
operation consisted of two procedures: First, the 
surgeon amputated at the middle third of the thigh 
in the usual way and ligated the vessels; second, he 
made an incision on the outside of the limb from the 
point of previous operation to the hip-joint. Then 
he detached the soft parts from the bone and disar- 
ticulated it. The patient made a good recovery. 

The first case of ovariotomy, by Dr. Ephraim" Mc- 
Dowell, of Kentucky (1771-18.30), was deliberately 
planned and executed by a surgeon who had never 




Fia. 4710.— Ephraim .McDowell (1771-1830). 

"seen so large a substance extracted, nor heard of an 
attempt or success attending any operation, as this 
required." The woman rode sixty miles on horse- 
back to the place of operation. The operation was 
performed in December, 1809. He states that an 
"incision about three inches from the musculus rectus 
abdominis, on the left side, continuing the same nine 
inches in length, parallel with the fibers of the above- 
named muscle, extending into the cavity of the abdo- 
men, the parictes of which were a good deal contused, 
which we ascribed to the resting of the tumor on the 
horn of the saddle, during her journey. The tumor 
then appeared full in view, but was so large that we 
could not take it away entire. We put a strong liga- 
•ture around the Fallopian tube near the uterus; we 
then cut open the tumor, which was the ovarium and 
fimbrious part of the Fallopian tube, very much en- 
larged. We took out fifteen pounds of a dirty, gelati- 
nou.s-looking substance, after which we cut through 
the Fallopian tube and extracted the sac, which weighed 
seven and a half pounds." The wound was closed 
with interrupted sutures and adhesive strips between 
them, and the ligature on the Fallopian tube was 
brought out of the lower angle of the wound. The 
report adds: "In five days I visited her, and, much to 
my astonishment, found her engaged in making up her 



bed. The patient returned home in twentv-five 
days in good health. It is reported that the operation 
created such pubhc opposition that a mob coUecte<l 
around the house in which it was performed, prepared 
to attack the surgeon if he failed. 

Twelve years later, in 1821, Dr. Nathan Smith, of 
New Haven, Conn., performed the operation of 
ovariotomy, having no knowledge of anv previou.s 
similar operation. Ho was led to make the operation 
from his observations in dissecting the body of a 
patient who had died of ovarian dropsy after being 
tapped seven times. The .sac was found to be the 
right ovarium, which filled the whole abdomen. The 
incision was closed with adhesive pla.ster and a band- 
age applied over the abdomen. No unfavorable 
symptoms occurred, and in three weeks the patient 
was able to walk about. 
^ The great operations of ovariotomy by Dudlev and 
Nathan Smith, unrecognized for half a. century, in- 
dicated the direction of the explorer for new "fields 
of conquest, before the pioneer appeared who dared 
to penetrate the peritoneum and effectively treat the 
viscera which it invested. Dr. J. Marion Sims, guided 
by the same inductive method of reasoning and in- 
sjjired by the scientific spirit which characterized his 
introduction of new methods of practice, not only ad- 
vocated the free exposure of the peritoneal cavity for 
the purposes of surgical operations, but he boldlv led 
the way in his operation for gall-stones. The result of 
his pioneer work has been the almost limitless expan- 
sion of the field of operative surgery. 

"Silver as a suture is the great surgical achievement 
of the nineteenth century," said Dr. J. Marion Sims 
(1813-1883) in his anniversary discourse before the 
New York Academy of Medicine in 1857. In this 
discourse Sims describes at length and eloquently two 
of the most important events in the history of the 
American practice of surgery, viz., the introduction of 
a silver wire as a suture, and the method of curing 
vesicovaginal fistula. The two discoveries were the 
result of a single course of experimental studies, 
"conducted," as the author states, "on the principles 
of a rational, inductive philo.sophy." The original 
purpose and object of Sims was the cure of vesico- 
vaginal fistula, .\fter repeated failures and a careful 
study of ever\-thing connected with the operation that 
might contribute to his want of success, he was finally, 
after four years of patient effort, led to the conclusion 
that the silk suture was the cause of failure. He had 
read the experimenis of Levcrt, of Mobile, Ala., made 
in 1829, at the suggestion of Physick, which proved 
that wire or lead caused no irritation, and also the 
statement of Mettauer, of \'irginia, that he had used 
lead wire in operations with success. Sims had, in 
fact, used lead wire in his experiments, but without 
success, and therefore he turned to silver as offering 
more advant.ages than other metals. He operated 
with silver wire on June 21, 1810, upward of three years 
after his first experimental operation, and with entire 
success. 

The first operation of Cholcctjstotomxj is attributed 
to Dr. John Stough Bobbs, a native of Green Village, 
Pa. He graduated from the Jefferson Medical 
College, Philadelphia, in 1S36. Our authority says, 
"Although attempts have been made to claim the 
honor of this operation for others the right of Dr. 
Bobbs to be considered the pathfinder in operations 
of this character has been generally acknowledged. 
Dr. Bobbs' patient, Mrs. E. Burnsworth, survived the 
operation for over forty years. The operation was 
performed June 15, lSt)7. \n incision was made be- 
tween the umbilicus and pubis, adhesions broken up, 
the gall-bladder located, incised and a number of 
gall-stones evacuated. The incision was sewed up, 
abdominal wound closed by sutures and adhesive 
plasters, and patient sat up in two weeks and rode out 
in four. 

53 



Suricory. Hl*<"f> "' 



KEFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



The rediiclion of ili.tlocalwris wjus a subject of Rroat 
interest to Britisli surgeons. Accordinfi to Mr. Pott, 
the Icmling authoritv in British surgery during the 
hitter lialf of the eighteenth eentur>-, dislocations were 
reduced bv powerful ai)paratus. Of the machines for 
that iMirpose, he savs: "Many or most of them are 
much more calculated to pull a man s joints asunder 
than to set them to rights.'' With true scientific in- 
tuition he declares that "replacing a di.slocatu)u 
would require very little trouble or force, were it not 
for the resistance of the muscles and tendons attacliei 
to and connected with them." Little if any useful 
i)rogre.ss was made in the direction pointed out by 
Pott, to determine the principles governing the re- 
duction of dislocations, until the attention of American 
surgeons was directed to the subject. Now, tlie most 
formidable of these dislocations, those of tlie femur 
at the hip-joint, are reduced in .\mericari (jractice 
without violence or pain, by siinple manipulation of 
the limb with the hands. The several steps m tlie 
l)rocess of investigation, by which the principles 
governing the natural and rational method of reducing 
all dislocations was discovered, illustrate the scientific 
spirit of .\merican practitioners as well as teachers 
of surgery. Phvsick reduced a dislocation of the 
femur by manipulation in 1812, after the pulleys had 
failed. He believed that the cause of previous failure 
was due to the escape of the head of the bone through 
a rent in the capsule, and that the head had become 
fixed as in a button-hole, from which he dislodged it. 
Dr. Nathan Smith, jjrofessor of surgery in Yale 
College, as early as ISll reduced a dislocation of the 
femur at the hip-joint by manipulations of the limb 
with the hands, without the aid of mechanical appli- 
ances. His method of procedure was based on a care- 
ful study of the action of the muscles attached to the 
upper extremity of the femur. 

In 1S,51 Dr. William W. Ueid, of Rochester, N. Y., 
published a jjaper on " Dislocation of the Femur on t he 
Dorsum Ilii. Reduction without Pulleys or Any 
Other Mechanical Power." He states that for ten 
years he studied the mechanism of these dislocations, 
and came to the conclusion that "the difliculty lay in 
the extension of the . . . adductors and rotators and 
that all traction ... on the di-slocated bone only 
increased this tension, and could do nothing toward 
bringing it into place, exce|)t at the hazard of almost 
certain rupture of some of these muscles or of fracture 
of the neck." 

Guided by the experience gained in his experiments, 
Reid practised manipulations and evolutions on the 
skeleton until he had determined that "dislocation of 
the femur on the dorsum illi . . . is reduced with the 
greatest ease in a few seconds or minutes, without 
much pain, without an assistant, without pulleys 
... or any other mechanical means, simply by 
flexing the leg on the thigh, carrying the thigh over the 
sound one upward over the pelvis, as high as the um- 
bilicus, and then by abducting and rotating it." 

Prof. Bigelow later reviewed the whole .subject of 
dislocations at the hip-joint and determined the peculi- 
arities of each and the special methods of reduction 
applicable to the different forms. The course of 
study which he pursued in demonstrating the Y'-liga- 
ment and its relations to the position of the head of the 
femur in the several dislocations, and the exact direc- 
tion in which the forces employed in reduction should 
be employed, forms one of the brightest chapters in 
scientific surgery. 

Fracture of the femur was the theme of constant dis- 
cu.ssion by French and British surgeons at the close of 
the eighteenth and the beginning of the nineteenth 
centuries. The controversy had become a national 
issue. Pott, on the part of the British surgeons, 
advised that the limb, flexed at the hip and knee, 
be laid on its side, suported only by lateral splints 
loosely applied, the body being inclined to that side. 
Desault, on the part of the F>ench, placed the limb in 

54 



an extended position and applied an external splint 
from the crest of the ilium to a point below the foot 
and attempted extension and countcrcxtension as the 
governing principle in the treatment of these fractures. 

It was in this particular feature of extension and 
countcrcxtension that an American surgeon perfected 
the method of treatment of fractures of the femur in 
the straight position. In 18(il Dr. Gurdon Buck 
(1807-1877), of New York, published an account of 
the method of treating fractures of the thigh in the 
New York Ho.spital, with illustrations. "Buck's ex- 
tension" is too well known to the students of surgery 
to require explanation. It is sufficient to state that its 
publication was the culmination of a century of per- 
sistent effort on the part of the most reputable sur- 
geons of Europe. 

Lithotomy was an operation of the first importance 
during the eighteenth century, and the various meth- 
ods of procedure w-ere subjects of endless discussion. 
In the progress of American practice both lithotomy 
and Civiale's operation of lithotrip.sy were destined to 
be supi^lanted. Bigelow, impressed with the great 
distensibilitv of the urethra as shown by Otis's experi- 
ments, began to use much larger evacuating tubes In 
the operation of lithotrity, with the result of being able 
to remove much larger fragments of the stone than 
formerly, and of thus reducing both the number of 




Fig. 4711.— Gurdon Buck (1807-1877). 

operations and the length of time of each trial. The 
new operation was gradually perfected under the title 
of "litholapaxy" (evacuation), and it has largely 
superseded all other methods of removing calculi from 
the urinary bladder. 

Hip-j<rint Disease was a fatal or a crippling affection 
of childhood which surgeons prior to the year 1800 
regarded as helpless and hopeless by any method of 
treatment. But American surgeons have stricken 
hip-joint affections from the catagory of incurable 
diseases and placed it among the more simple and cur- 
able forms of sickness peculiar to childhood. 

The history of the discovery of the proper treatment 
is as follows: Dr. Physick was taught by his preceptor, 
Hunter, that rest is the first and essential factor in the 
correct treatment of inflammation. He applied that 
principle to the treatment of hip-joint disease, about' 
the year ISOO. The final question in the problem was: 
How can fixation of the joint and traction of the leg be 
effected while the patient is allowed to walk? The 
clue to the answer was given by Dr. Henry G. Davis, 
of W'orcester, Mass., in 1860 who devised a .splint 
which imperfectly effected the object but which sug- 
gested to Dr. Lewis .\. Sayre, of New Y'ork, not only the 
essential features of a rightly constructed hip splint, 
but enabled him to detect the causes of previous fail- 
ures to meet conditions necessary to success. The 
result of this half century of studies was in the highest 
degree creditable to American surgeons. The class of 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



Surgery, History of 



children that at the beginning of this period died after 
years of intense suffering, confined to their beds, arc 
to-day met upon the streets, at school, and on the 
playgrounds, in the enjoyment of healthful activity, 
while wearing the splint that effects the cure. 

The scientific treatment of diseases of the appendix 
vermiformis is largely due to the American practice of 
surgery. The operation of Hancock, of London, who 
in 1848 deliberately opened an abscess formed in the 
region of the appendix and cured his patient, was 
brought to the attention of American surgeons in IfHHT 
by a paper of Dr. George Lewis entitled "A Statistical 
Contribution to Our Knowledge of Abscess and Other 
Diseases Consequent Upon the Lodgment of J'oreign 
Bodies in the Vermiform Ajjpendix." Dr. Willard 
Parker, of New York, rejjeated the operation of Han- 
cock, and in 1867 published the histories of four cases 
on which he had operated. In all his cases but one he 
did not operate until fluctuation was distinct, indicat- 
ing the existence of an abscess. In the one case he was 
uncertain as to the existence of an abscess, but he ven- 
tured to operate and saved his patient. He did not 
advocate an early operation, but advised a delay as a 
rule until it was determined that suppuration had 
occurred, believing that an operation was required 
only when it was certain that pus had formed. 

Parker's operation only sought an evacuation of pus 
as in opening an ordinary abscess, the offending appen- 




FiG. 4712.— Crawford W. Long (1816-1878). 

dU being left in the wound. The next step was the 
removal of the appendix, which was done in this coun- 
try in May, 1886, at Roosevelt Hospital, New York, 
by Dr. R. J. Hall. The operation was finally per- 
fected by the removal of the appendix, as its essential 
feature, regardless of the existence of suppuration. 

We have not space to illustrate American surgery 
farther and will close with an account of the two most 
important epochal events in the development of sur- 
gery, anesthesia and asepsis, which stand like great 
beacon lights brilliantly illuminating the patliway 
of progress of the nineteenth century, and indeed of all 
future time. 

The introduction of anesthesia and asepsis into the 
practice of surgery were the epochal events of the nine- 
teenth century. As they represent the scientific spirit 
of British and .American surgery and the crowning 
events of the history of surgery, we place them together 
in this concluding section in chronological order. 

Anesthesia and Anesthetics (Massachusetts Gen- 
eral Hospital, October, 1846). — The discovery of a 
method of safely rendering a patient insensible during 
an operation was the most important epoch in the his- 
tory of surgery prior to 1846. There are several 
allusions to efforts to obtain such a result in the writ- 
ings of early medical authorities. In 1800 Sir Hum- 



phrey Davy (1728-1829) of Penzance, England, experi- 
mented upon himself with nitrous oxide, and stated 
that "it may probably be used with advantage in 
surgical operations in which no great effusion of blood 
takes place" (Garrison). The clue to the great dis- 
cover3- which Davy's experiment revealed was inde- 
pendently discovered and utilized by an American 
country physician nearly half a century later. The 
incident was so removed from observation that it was 
unknown to the profession for several years. "The 
interesting facts of that discovery are as "follows: 

Dr. Crawford Williamson Long (181.5-1878) of 
Danielsville, Ga., a graduate of the Medical Depart- 
ment of the University of Pennsylvania, was im- 
pressed with the effects of nitrous oxide gas — "laugh- 
ing gas "^-as administered in schools for amusement. 
and personally submitted to a test of its effects oil 
himself. While under its influence he received a 
severe blow upon his leg of which lie was not conscious 
until he recovered from the effects of the gas. It 
occurred to Dr. Long that surgical operations might 
be performed while the patient was in this insensible 
state without conscious pain. Accordingly, in 1842. 
he removed a small tumor from the neck of a young 
lady successfidly as regards freedom from pain. He 
repeated the use of gas in operations several times, but 
did not publish any account of his work until stimu- 
lated to do so by the reported cases of successful 




Fig. 4713.— William G. Morton. (1819-1S68). 

operations under an anesthetic, in Boston. The peri- 
odical in which he published his cases had but a 
limited local circulation and hence his work gained 
no immediate notorietv in the profession. 

In 1844, Horace Wells (1815-1848), a dentist of 
Hartford, Conn., was led by his observations of the 
anesthetic effect of nitrous oxide to have a tooth 
extracted while under the full influence of that gas and 
on recovering cried out, "A new era in dentistrv!" 

William Thomas Green Morton (1810-1868)," of 
Charlton, and Boston, Mass., was a former partner of 
Wells and to him Wells related his discovery and new 
method of practice. Morton adopted the practice 
with equal success. On relating his experience to 
his former preceptor. Dr. Charles T. Jackson, a 
chemist, the latter advised him that chloric ether was 
an anesthetic, which Morton used succe.ssfully. 
Subsequently, Jackson recommended sulphuric ether 
as more easily managed. The utiliz.ation of anesthe- 
sia in operative dentistry had proceeded thus far when 
Morton determined to have it tested in the practice of 
operative surgery. He thereupon applied to Dr. 
John Collins Warren, one of the most eminent sur- 
geons of that period, who consented to give the ether a 
trial in the Massachusetts General Hospital. The 
case was selected, the day appointed — October 16, 
1846 — a large number of surgeons and iihysicians were 
in attendance in a state of intense expectancy. The 



Surgery, History of 



REFEREXCE HANDBOOK OP THE MEDICAL SCIENCES 



patient was on the operating table, the surgeon and 
his assistants were in position to proceed, but Dr. 
Morton with his anesthetic had not arrived. The 
suspense and di.sappointment led Dr. Warren to inti- 
mate that he had little faith in the propo.sed anes- 
thetic, when Morton came in evidently much excited, 
and explained that he required a special instrument 
with which to admiTiister the ether and the manufac- 
turer had delayed him. 

The operation consisted in the removal of a vas- 
cular tumor on the left side of the neck. The patient 
came under the effects of the anesthetic readdy and 
manifested no sign of ))ain during the operation, w;hich 
lasted five minutes, and quickly recovered consciou.s- 
ness. A most profound impression was made on the 
surgeons present and Dr. Warren remarked, "Gen- 
tlemen, this is no humbug." But neither Dr. Warren, 
nor his audience could at the moment have had any 
adequate conception of the immense stride which 
surgery made during that five minutes. Practically, 
it took its position in the front rank of the great hu- 
mane sciences of modern civilization — a position which 
it will henceforth maintain. 

On the following day Dr. Hayward, of the same 
hosj)ital, removed a large tumor from the shoulder of a 
patient whom Morton etherized and with the same 
success. Other operations followed, and on Novem- 
ber 18, 1846, Dr. Henry J. Bigelow, published the 
facts of the discovery to "the world in the Boston Med- 




Flii. 4711 All liarly ( )|)i-niti.)n uniler Etlu-r Aii.slhcsia at the 
Ma&sacliUiiett!) General Hospital. 

ical and Surgical Journal. Dr. Oliver Wendell 
Holmes suggested the term "anesthesia." 

A most unhappy controversy subsequently arose 
between Morton, Wells, Jackson, and Long as to 
priority in the discovery of etherization. Morton 
patented the article under the title of "lethcon," in 
lS4t), without revealing its true name and then sought 
to obtain from Congress the sum of S200.000 as a 
gratuitv for the discovery. This latter act brought 
the claims of The four contestants before an investi- 
gating committee which, owing to the conflicting 
testimony, failed to recognize either as entitled to 
compensation. 

In November, 1847, chloroform was announced i^s 
an anesthetic by Sir .James Young Simpson (1811- 
1870) of Edinburgh. He had u.scd sulphuric ether in 
obstetrics on January 19, 1S47, the first case in Great 
Britain, and was led to substitute chloroform which 
he had personally tested with his friends, Duncan and 
Keith. This new anesthetic became immediately 
popular owing to its agreeable odor, its unirritating 
qualities and its prompt action. But its popularity 
was soon imperilled by reported deaths from its use. 
Experience has demimst rated that ether is the safer 
anesthetic for genera! employment. The possibilities 
of anesthesia having been established by these pioneer 
discoveries a variety of agents having this effect 
have since been announced and subjected to trial. 

The result of the discovery of practical anesthesia 
was an enormous widening of the field of operative 
surgery, scientilic precision in its practice and, as a 

56 



corollary, a far higher ratio of success. The first 
proposition was demonstrated at Massachusetts 
General Hospital where the discovery of anesthesia 
was first made public as follows : During the ten years 
prior to the use of anesthetics 385 operations were 
performed, or thirty-eight annually, but during the 
ten years after the use of anesthetics 1893 were re- 
corded, or 189 annually. 

The announcement of the discovery was received 
by the surgeons of Europe with doubts and mis- 
givings, but it soon gained universal credence under 
the leadership of three eminent surgeons of the period, 
viz., Robert Liston (1794-1847), of London, who am- 
putated a leg under ether in December 1840; James 
Svme (1799-1870), of Edinburgh, adopted anesthesia 
iii 1847; and Pirogoff (1810-1881) of St. Petersburgh, 
wrote a manual on anesthesia in 1847. 

The chief value of anesthesia in operative surgery is, 
that complete relief of the surgeon from the neces.sity 
of haste which insures precision in all of the details of 
the operative procedure, even to the closing of the 
wound and the adjustment of the dressings. _ 

There is a monument standing in the Public Garden 
of Bo.ston on which is inscribed the verdict of history 
as to the honor and glory of introducing anesthesia 
into the practice of surgery: 

To covimemorale the discovery that the inhnhng 
of ether causes insensibiliti/ to pain, firxl proven 
to the irorldat the Massachiifelt.td mral Ilnxpi- 
tal in Boston, October, A.D. MDCCCXLVI. 

A.sEPSis AND Antisepsis (Joseph Lister (1827- 
1912). — The healing of wounds by suppuration, or 
by "second intention," had hitherto been the chief 
obstacle to success. The operation in all of its details 
may have been performed with the greatest precision 
an(i yet final success was not assured owing to the 
formation of pus in the cavity of the wound which not 
only prevented healing but too often proved a source 
of f.ital septicemia or an exhaustive drain upon the 
vital resources of the patient. It has been noticeable 
in the past history that some of the more prominent 
surgical writers mention favorably the healing of 
wounds without suppuration, or by "first intention." 
Hippocr.ates makes special allusion to the importance 
of the immediate healing of wounds. Undoubtedly 
some of the applications which were formerly made to 
arrest hemorrhage acted as preventives of suppura- 
tion, but no definite knowledge of the actual nature or 
cause of pus existed. Indeed, pus was so constantly 
present in wounds that it was regarded as a necessary 
part of the healing process and surgeons estimated the 
condition of the wound by the apparent quality of 
the pus. If it was thick like cream it was called 
"laudable pus," indicating a healthy state of the 
wound. 

In the year 1867 the second greatest, if not the great- 
est, epoch in the history of surgery was announced in 
terms implying the immediate healing of wounds with- 
out suppuration. So contrary was this announce- 
ment to the universal experience of surgeons that it 
met with general derision. The very few surgeons 
who attemjjted to test the method prescribed were 
unmercifully ridiculed, especially by their seniors. 
Hut as the new procedure was based on the immutable 
deductions of science it was destined to survive all 
opposition and become the most important feature of 
the surgery of the future. 

Joseph Lister, the founder of aseptic surgery, was 
a native of Upton, Essex, England. He graduated in 
medicine at the University of London, in 18.52, and 
went to Edinburgh where, in 1854, he became house 
surgeon under Syme whose daughter he subsequently 
married. Syme was at that time the leading British 
surgeon, both as an operator and teacher, and Lister 
was well placed preparatory for his future work. 
From an early period in his professional career Lister 
had manifested a genius for original research. Soon 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



SuKpen§ory BandaKefi 



after graduation he studied tlie histology of muscles 
and in the publication were his own drawings in 
illustration. 

In 1800 he was appointed professor of surgerj- in the 
University of Glasgow and from this time he began to 
take rank among the junior surgeons of the period. 
A notable paper on excision of the wrist for caries 
appeared in 18G5 {Lancet). His studies which led 
to the employment of antiseptics in the treatment 
of wounds began while engaged in hospital work under 
Svrae. Though Syme was very careful to protect 
wounds from irritation by foreign substances, as 
sutures, dirt, soiled dressings, there was still suppura- 
tion due to conditions as yet unknown. Lister found 
in the statistics of his amputations (1864-1866) a mor- 
tality of forty-five per cent, though he exercised 
the greatest care in protecting the wounds. 

Pasteur's theory that microorganisms are the cause 
of putrefaction came to Lister's attention and his 
observation that putrefaction was present only when 
there was suppuration, suggested to his mind the ex- 
planation of the cause of serious complications of 
wounds, as septicemia, erysipelas, gangrene, and heal- 
ing by "second intention." He at once began experi- 
ments both in the laboratory and in the wards to 
determine the truth of the suggestion, employing such 




Fig. 4715. — Joseph Baron Lister (1827-1912 1. 

agents as he believed would destroy the microorganisms 
with the least injurj' to the patient. After several 
experiments he was led to use carbolic acid which was 
being employed as a disinfectant of sewage in a 
neighboring town. The first trial was on August 12, 
1805, and the case was a compound fracture; the re- 
sult was altogether satisfactory. Lister continued 
his experimental work until 1807 when he published 
a paper entitled, "On the Antiseptic Principle in the 
Practice of Surgery" {Lancet). 

.\ tempest of criticism and ridicule greeted the 
author of the paper. He was accused of not being 
original in his work; of not obtaining better results 
than by the old method of practice; of rendering opera- 
tions tedious and tiresome beyond endurance; of 
using childish and ridiculous apparatus and dressings. 
Meantime, Lister continued his experiments which led 
him to modify the methods employed both as to the 
antiseptic agents used and to the material dressings 
and tiieir application, but he never wavered in his 
belief of the fundamental principles on which the 
practice of aseptic surgery rests, viz., the absolute 
necessity of destroying all microorganisms in wounds 
to secure freedom from supi)uration. The answer 
which Lister made to his critics was the performance 
of operations of the most serious character followed 
by healing of wounds without pus or temperature. 
His reports of excision of the knee-joint (1S7S), 
of wiring a fractured patella (1883), and other capital 
operations, without pus or fever, the wounds healing 



by "first intention," were simply incredible. Like all 
great discoveries anesthesia and asepsis had to pass 
through a campaign of denunciation and ridicule but 
being securely founded on science they won every test 
of their intrinsic value and are now in universal use. 

With the discovery of anesthesia and asepsis and 
their universal introduction into practice, during the 
last half of the nineteenth century, we bring to a close 
the history of the epochal events which marked the 
progress of surgery from its obscure origin among 
primitive peoples of prehistoric times to its perfection 
as an art and science at the beginning of the Twen- 
tieth Century. Necessarily it is but an outline, a 
superficial sketch, and cannot have the hLstorical 
value of a formal, detailed review of the many collat- 
eral subjects and important questions with which a 
profession like surgery must be concerned in its de- 
velopment. But this form of a historical sketch is 
believed to have the advantage of more thoroughly 
familiarizing the student with those higher elements 
in promoting progress which illustrate the genius of 
surgery. Baas, the eminent historian of medicine, 
remarks: "An acquaintance with the views and the 
knowledge of epochs already submerged in the shore- 
less ocean of time, frees the mind from the fetters and 
currents of the day, with its often oppressive restraint, 
widens the horizon for a glance into the past, and an 
insight into the present of human activity deepens the 
view for a comprehension of the ideas which guided 
the earlier and the more recent physicians, and gives 
on the other hand to our daily professional labor a liigh 
consecration." Stephen Smith. 



Suspensory bandages are employed for prophy- 
lactic purposes when the scrotum and its contents are 
normal, but exposed to injury or disease. Thus they 
are recommended to men whose occupation compels 
them to stand for hours in the upright position, to lift 
heavy weights, to take severe physical exercise, or to 
ride a horse or a bicycle for hours at a time. Athletes 
usually wear bandages technically called "jock- 
straps" in place of suspensories. These "jock- 
straps," however, while immobilizing the external 
genitals, drag them upward, and, in fixing them upon 
the pubes, may produce abnormal pressure of the 
scrotal contents, and expo.se them to the injuries 
which they are intended to prevent, .\mong the 
prophylactic uses of suspensory bandages, they are 
recommended in gonorrhea to prevent epididymitis 
and orchitis. Experience, however, has proven 
that they are not always effective in this regard. The 
therapeutic uses of suspensory bandages are as varied 
as are the diseases which affect the scrotum and its 
contents. In general depressed states, where re- 
laxation of the scrotum causes it to hang down below 
its normal level, a well-fitting and properly adjusted 
suspensory bandage gives the organs within it the 
needed support. In local conditions, such as scrotal 
dermatoses, it .ser\-es to immobilize the sac and thus 
compels any medicaments which may be applied to 
the skin to remain in direct contact therewith. In 
varicocele of a minor degree it oftentimes renders 
operation unnecessary. In funiculitis, epididymitis, 
orchitis, and orcho-cpididymitis, when the swelling 
is not too great to be controlled by a suspensorj' 
bandage, it serves its purpo.se admirably. When the 
swellings in these diseases are very great, they require 
modifications of suspensory bandages, called com- 
pressors. These modifications not only support the 
scrotum firmly against the ascending rami of the 
pubis, but, having a firm, strong bag with lace-strings, 
they render it possible to subject the scrotum and 
its "contents to uniform compression. It is essential 
to suspensories and compres.sors that traction should 
be exerted in a posterior direction upon the lower 
(posterior) apex of the bag. This traction is made by 
means of counter-straps. If these straps are omitted, 

57 



Suspt-iiNur) UaiiilaK>' 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



I 



as tlii-v soniotiines are, cspi'C'ially in the cheaper forms 
of suspensories, these contrivances then become useless 
anti even at times injurious. Firm support and com- 
pression are not possible without these counter-straps 
When they are absent the scrotum is dragged upward 
and forward bv the waist-band, and the posterior 
margin of the bag is likely to cut into the posterior 
surface of the scrotum. Many forms of excellent 
suspensorv bandages are made, but no one form can 
be recommended for all prophylactic or therapeutic 
uses The individual conformation of the external 
genitals varies as much as does that of the hand or 
foot. Suspensorv bandages must therefore be 
"fitted" to the genitals, with consideration for the 
individual peculiarities as well as for the object to be 
attained. The indexible rules regarding the efTcctive 
use of suspensorv bandages are, first, that they mu.st 
not i.roduce the slightest discomfyrt and next, tha,t 
thev mu.st instantaneouslv give at least marked, it 
not" entire, relief from pain. If these ends are not 
attained, the bandage employed is not applicab e to 
the ca.se or has been defectively applied. In epididy- 
mitis when the cord is not much involved, strapping 
the testicle by Fricke's method often enhances to a 
marked degree the value of a suspensory band.ige. 
It must be remembered, however, that the application 
of strips of adhesive plaster for the accomplishment 
of the desired end is painful, unless it be done by an 
operator of great experience in the use of this form of 
dressing. When it is properly applied this dressing 
promptlv reduces swelling and pain, and renders the 
patient 4ntirelv willing to have the operation repeated 
as often as may seem desirable. Gerson of Herlm 
devised "scrotal" elevating strips" as a substitute for 
suspensory bandages. These strips {SuKpensionshin- 
deii) are elastic adhesive bandages, with the upper 
margin softly fringed. Before applying them it is 
desirable to emptv the lower part of the scrotum as 
much as possible bv crowding the testicle firmly up 
against the external ring. In a certain number of 
cases these strips prove successful, and as it is an easy 
matter to apply them thev may well be recommended 
for trial Ferd. C. Valentine. 



Sweet Chalybeate Springs. — AUeghany County, 
Virginia. 

Post-office. — Sweet Chalybeate Springs. Hotel 
and cottages. 

Access. — Via Chesapeake and Ohio Railroad to 
.\Ueghany Station, the highest point on the Chesa- 
peake and Ohio, thence a drive of nine miles to the 
springs. . ,11 

These well-known springs are ensconced in a lovely 
valley on the backbone of the Alleghany Mountains, 
at an elevation of 2. 1500 feet above the sea. The 
location is in the midst of the "Springs Region," 
and whatever mav be said regarding the salubrity of 
climate, the charm of scenery, and the general at- 
tractiveness of the Old Dominion mountain resorts, 
may be fittingly applied to these springs and their 
environments. "Among the more immediate desir- 
able features may be mentioned a comfortable, modern 
hotel with acconiinodations for 300 people, a commodi- 
ous bathing establishment with facilities for hot and 
cold mineral-water bat lis, and inclosed pools for plunge- 
bathing in flowing water. The section round about 
abounds in deer and other mountain game, while the 
streams afford excellent fishing. The springs, fonnerly 
known as the Red Sweet Springs, are situated in one 
of the most beautiful valleys of Virginia. So far as 
chemical composition is concerned, their waters do not 
show any verv marked differences. The combined 
flow of tlie thre"e is about 4S,000gallons per hour. The 
following analysis was made by Prof. W. B. Rodgers. 

This is a very good calcic-chalybeate water. Its 
taste is somewhat sweet, but ferruginous. Its tem- 



perature at the fountain is about 79° F. The water 
is beneficially emploved in anemia, chlorosis, leucor- 
rhea, and other conditions indicating an impover- 
ished state of the blood. It has also proved effica- 
cious in neuralgia and ga.stralgia and other disorders. 
Various amusements are provided for the guests. 

Dne United States Gallon Contains- 

Solids. Grains. 

Iron carbonate 32.0 

Iron oombined 16 

Calcium carbonate 64 . 

Magnesium carbonate 48.0 

Magnesium sulphate 16.0 

Silica 16.0 

Sodium hydrochlorate 8 

Nitrogen 1" -'S 

Ojygen ^O.O 

Carbonic acid gas 103 27 cubic inches 

Emma E. Walker. 



Sweet Springs. — Saline County, Missouri. 

Post-office. — Sweet Springs. Hotels. 

Access. — Via the Lexington branch of the Missouri 
Pacific Railroad. 

The location is fifteen miles from the Missouri Blue 
Lick Springs. 

These springs are five in number and have a flow of 
224 000 gallons hourly. The temperature of the water 
is .54° F. Analyses "of two of the springs have been 
made by Prof. Charles P. Williams: 

One United States Gallon Contains: 



Akesion 
Spring. 
Grains. 



Calcium carbonate . . 

Iron carbonate 

Manganese carbonate 
Sodium sulphate .... 

Calcium sulphate 

Barium sulphate .. . . 
Calcium phosphate . 
Magnesium nitrate .. 
Ammonium nitrate . 

Sodium chloride 

Calcium chloride . . . 
Potassium chloride . . 
Magnesium chloride . 
Lithium chloride . . . . 
Magnesium bromide. 

Aluminum oxide 

Silica 

Organic matter 

Total 



40.25 
0.27 
0,20 
2,61 

57.93 
8.15 
0.24 
0.18 
1.17 
756 . 11 

74.79 

28.56 



Sweet 
Springs. 



9.56 
0.57 
Trace 



89.62 
14.72 
3.40 
22.29 
0.05 
0.12 
0.09 
1.08 
4.05 



It will be observed that there is a great difference in 
the strength of these waters, the Akesion Spring being 
much more potent. The spring also contains a con- 
siderable amount of sulphureted hydrogen. It is 
especially recommended for diseases of the liver. The 
water of the Sweet Springs is recommended for dis- 
eases of the kidneys and bladder, various forms of 
dyspepsia, and in many diseases of women and chil- 
dren. An excellent bathing establishment is main- 
tained at the springs, baths being supplied by water 
from the salt-sulphur spring, five miles distant. 
There are also white and black sulphur springs in 
the neighborhood. Emma E. Walker. 

Sycosis. — {Syno7)yms: Folliculitis et perifolliiu- 
litis barbfe; sycosis non -parasitica.) Sycosis is a dis- 
ease of the skin that primarily affects the hair follicles. 



58 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



In most cases it occurs on the bearded portion of the 
face, but it may occur anywhere wliere there are coarse 
hairs, as on the scalp, eyebrows, axillae, pubes, and 
even on the limbs of coarse-haired individuals. It 
has been called barber's itch, which is wront;. as that 
is ringworm of the beard. The term "non-parasitic 
sycosis" is also erroneous, as we know that the dis- 
ease is parasitic, though not due to the trichophyton 
fimgiis. 

■SniPTOMS. — First, as it occurs on the face. The 
disease begins by the eruption of a number of red. 
inflammatory, conical papules or nodules scattered 
over the whole or part of the bearded portion of the 
face. The lesions are discrete, and it will be noticed 
that each one is pierced in its center by a hair. The 
skin between the lesions is unaffected. If the onset is 
very violent, so that a large number of hairs are 
affected, the individual zones of redness will meet and 
then the whole of the affected area will be reddened 
and somewhat swollen. The lesions vary in size from 
that of a millet seed to that of a pea. Unless the 
disease is promptly relieved by treatment the papules 
give place to pustules, which likewise are pierced by 
hairs. The pustules show no tendency to run to- 
gether and form patches as do those of eczema. 
After a time the pustules dr>- up and small crusts form 
about the hairs. If the disease is very intense in- 
filtrated patches will form, and, instead of pustules, 
there may be small abscesses. New papules continue 
to form and undergo their evolution into pustules, 
so that we find both forms of lesions present at the 
same time. The hairs in the pustules early lose their 
luster. While at first firmly seated in their follicles 
so that attempts at depilation are painful, when the 
pustules are fully formed the hairs come out easily 
and without much if any pain. When the hairs are 
extracted early their root sheaths appear as glassy 
cylinders, .-^fter the pustules form the root sheaths 
will bo yellowish and swollen with pus. While 
u-sually the hair is not permanently damaged, in 
chronic cases the hair papillae are destroyed, the beard 
is thinned, and small cicatrices are seen. 

The course of the disease is chronic, marked by 
relapses, the disease being at one time apparently 
cured, and then breaking out again with renewed 
•violence. 

Any part of the bearded portion of the face may be 
attacked. The disease is specially common on the 
upper lip. Usually there will be found at the same 
time a catarrhal or purulent discharge from the nose. 
The cheeks are the parts next most frequently af- 
fected, either one or both. The disease may occur 
symmetrically. It may be limited to a single area. 
As a rule it does not occur below the angle of the jaw. 
If it does occur there it is usually by extension from 
the cheeks. With it there is no eruption upon the 
non-hairy parts of the face. Not uncommonly the 
eyebrows and the eye-lashes are affected at the same 
time as the cheeks. 

There is little if any itching, the patient complaining 
rather of a feeling of soreness, distention, or burning. 

Secoiidhi, as it occurs on other parts. On the eye- 
brows and pubes and in the axilla^ the appearances 
are similar to what obtains on the face, and the course 
of the disease is the same. On the scalp we meet with 
the characteristic papules and pustules pierced by 
hairs. When the disease occurs on the limbs (and 
it is mostly on the legs that it occurs), we find the 
same lesions; but, as the hair is more sparse, there is 
not the .same tendency to form diffuse patches, the 
lesions remaining discrete throughout. 

Lupoid sycosis is a very severe form of the disease 
that occurs in patches with vesicopustules of the 
mouths of the hair follicles, crusts, and redness of the 
skin. When the crusts fall the skin is found to be 
cicatricial. It is very chronic in its course and may 
involve a large part of the beard. 



Etioloov. — There is no doubt that the disea.se is 
parasitic. The majority of investigators a-scribe its 
origin to the invasion of the hair follicles by the 
Staphylococcus aureus et alhus. Sabouraud states 
that it is due to the Staphylococcus aureus alone. 
Unna teaches that there are two varieties of the dis- 
ea.se, one of which he names the coccogenie, being 
due to the Staphylococcus aureus et alhus; and the 
other bacilligenic, being due to an organism which he 
calls Bacillus sycosiferus fatidui. 

The disea,se is contagious, and barber shops are, 
without doubt, a frequent source of contagion. Like 
many other diseases due to microorgani.sms, there 
are two factors at work — one the predisposing cause, 
the character of the soil; and the other the exciting 
cause, the microorganism. Eczema is sometimes 
the forerunner of sycosis. Otherpredisposing agencies 
are irritant applications to the .skin, such as mustard 
or other poultices, inton.se heat, cosmetics, and the 
like. A nasal discharge is the predisposing cause of 
sycosis of the upper lip. Shaving with a dull razor 
is supposed to be the cause in .some cases, but tho.«e 
who do not shave are by no means exempt from the 
disease. Most patients with sycosis are in poor 
general condition. Men naturally are the most 
frequent sufferers from the disease. 

Pathology. — Sycosis is primarily a perifolliculitis, 
the hair follicle and the sebaceous glands being affected 

secondarily. 

DiAGXOSis. — The two diseases from which sycosis 
must especially be differentiated are eczema and 
ringworm of the beard. 

Eczema may be limited to the bearded portion of the 
face, but it is prone to pass over to the non-hairy 
parts; sycosis is confined to the hairy parts. Eczema 
is very pruritic and the skin is scratched; sycosis is 
not pruritic and the .skin is not scratched. The 
lesions of eczema bear no special relation to the hairs; 
it is a catarrhal disease of the skin, and the hairs are 
affected as it were accidentally and superficially. 
No matter how bad an eczema may be, it never 
destroys the hair. Sycosis is primarily a disea.se of 
the hair, the skin between the individual hairs is 
unaffected except in very bad cases, and the hair may 
be destroyed. In eczema cru.sting is a feature of the 
disease, and when the crusts are removed a raw and 
oozing surface is exposed. In sycosis the crusts are 
usually confined to the hair follicles. If diffused 
crusts are formed, when they are removed it will be 
found that the hairs stand in little inflammatory 
areas while the inter\'ening skin does not present a 
moist surface as is the case in eczema. In some cases 
it is impossible to make a diagnosis at first, but it is 
arrived at by studying the effect of treatment, sycosis 
being more intractable than eczema, and the follicular 
character becoming more pronounced as the disease 
approaches recovery. 

Ringii'orm of the beard usually occurs on the chin 
and neck below the angle of the jaw; sycosis occurs 
wnst often on the upper lip and cheeks. Ringworm 
occurs either as a superficial scaly ring or as large- 
sized nodules arranged in circles and segments of 
circles; sycosis occurs as an eruption of papules and 
pustules pierced by hairs and without any grouping. 
In ringworm the hairs are broken and split and can 
be pulled out readily though the root is often left 
behind; in sycosis the hairs lose their luster, but other- 
wise are unaffected, and in the early stages attempts 
at removing them are very painful. Ringworm once 
cured does not tend to relapse; sycosis does. Under 
the microscope the hairs from a case of ring\vorm 
will be found loaded with spores and mycelia; in 
sycosis microorganisms are found not in the hair but 
in cultivations from the follicle contents. 

Aoie should offer no difficulty in diagnosis, as it 
occurs all over the face and comedones are alwaj-s 
present. 

59 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



Phoonoris.— While the disease is essentially chronic, 
it is curable. Permanent loss of hair is exceptional. 

Treatment. — When the upper lip is affected it i.s 
necessary first to seek out and cure any disease of the 
mucous membrane of the nose that may be present. 
In all ca.ses attention to the general health should be 
given, so as to improve the character of the soil and en- 
able it to resist the invasion of the microorganism. 1 he 
skin must be proteited from irritation. The conges- 
tion of the skin tliat is often present in acute cases 
should be relieved bv the administration of laxatives. 
Tliere is no specific for the disease. Locally, the treat- 
ment will varv with the stage of the disease. At the 
beginning the'inflamniation may be treated by bathing 
the affected parts with hot water and following this 
with an alkaline lotion, such as black wash, lead and 
opium wash, or a zinc lotion containing two per cent, 
of salicylic acid. In some cases the application of six 
drams of the ointment of the ammoniate of mercury 
and two drams of cold cream will abort the disease. 
When i)ustules have formed the hairs should be 
plucked from the di.seased follicles — a conservative 
process, as it tends to prevent the destruction of the 
liair papillae If there are a huge number of pustules 
a rapidfv favorable effect may be produced by going 
over the face with a dermal curette, after which the 
parts should be bathed with a 1 to 1,000 solution of 
bichloride of mercury. If crusts are present they 
should be removed by .soaking them at night with a 
two-per cent, solution of salicylic acid in sweet oil, and 
washing them off on the next day with soap and water. 
The applications advised above may be used. Di- 
achylon ointment, made according to Hebra's formula 
and spread on cloths and bound down on the face, is 
an excellent remedy. 

In more chronic conditions sulphur ointment is 
often a sovereign remedy. An ointment of salicylic 
acid 15 grains, precipitated sulphur 1 dram, lanolin 
.=) drams, goose grease 1 ounce, applied twice daily 
will be found useful. The employment of tumenol 
is at times followed by brilliant results. It may be 
used diluted 1 part in 10 parts of vaseline or other oily 
base. Tar ointment may be used as well as ichthyol 
or resorcin in five to twenty per cent, strength. Auto- 
genous or stock vaccines of mixed staphylococci often 
prove curative. Their action is increased by the 
daily application of hot water to the affected areas. 
The dose is from 50,000,000 to 100,000,000, repeated 
and increased every sixth day up to 300 or 400 million. 
If the clinical appearances become decidedly wor.se, 
a pause should be made and the treatment resumed 
at a smaller do.sage. In very obstinate cases we may 
have to resort to stimulation by means of scrubbing 
with green soap and then binding on zinc-oxide oint- 
ment. It is best to keep the beard clipped short dur- 
ing treatment. Epilation is advised by many authori- 
ties. Many cases have been cured by both radio- and 
phototherapy. As the disease is a most obstinate 
one, we shall have to make many changes in our treat- 
ment before we succeed in curing it. It is well to 
continue .some protective applications for several 
weeks after the disease seems to have been cured. 
George Thomas .Iacksox. 



Sydenham, Thomas. — Born at Wynford Eagle, 
Dorsetshire, Knglaiifl, in 1624. At the age of eight- 
een he entered Magdalen College, Oxford, and 
remained there until 1644, when he enlisted in the 
Parliamentary Army. After a brief military service 
he resumed (1645) his studies at Oxford and received 
his Bachelor's degree in 1648. It was only at a much 
later date (1676), however, that he was given the 
degree of Doctor of Medicine, and then not by Ox- 
ford, but by Cambridge, .\fter leaving Oxford he 
first spent a few months at the Medical School of 
MontpcUier, France, and then settled (1666) in the 

60 



metroi)olitan district of Westminster as a medical 
practitioner, the necessary license having been 
granted him by the College of Physicians of London. 
His first medical treatise, which bore the title " Meth- 
odus curandi febres," was published in 1666. The 
third edition of this work was issued ten years later, 
but with the title changed to " Obscrvationes medicse 
circa morborura acutorum, etc." Between 1666 and 
1683 he published several other treatises, the more 
important of which deal with epidemic diseases, with 
lues venerea, with smallpox, with gout, with dropsy, 
and with hysteria. 

During the later period of his career Sydenham 
attained great celebrity as a physician, but this celeb- 
rity would have been short-lived if it had rested on 
nothing more substantial than mere cleverness and 
professional success. As a matter of fact he had 
effected, by his teaching and also by his example, a 
most important revolution in medicine, and it was 
the appreciation of this fact which led the physicians 




Fig. 4716— Thomas Sydenham (,1624-1689). 

of England to bestow upon him the appellation' of 
"The English Hippocrates," and which ultimately 
gave him so highly honorable a position in the his- 
tory of our profession in general. A brief considera- 
tion of the state of medicine in England during the 
seventeenth century will enable the reader to under- 
.stand the full importance of the change which Syden- 
ham was instrumental in bringing about. 

The physicians of that period were split up into 
three great sects — the followers of Galen, with whom 
should be classed the Graeco-Arabists; the iatro- 
chemists; and the iatrophysicists. 

The first of these groups, the Galenists and the 
Graeco-Arabists, were largely intent upon interpreting 
in the strictest manner possible the writings of Hippo- 
crates, Galen, and some of the Arabian authors. It 
was their rule to follow the teachings of these ancient 
writers slavishly. Instead of studying the different 
diseases "from nature," if we may use that expres- 
sion, they devoted their time and thoughts largely 
to the task of interpreting correctly the words used . 
by these fathers in medicine. Their work, in other 
words, partook of the nature of philology. Real 
progress in the science of medicine was of course not 
attainable along this route. The men composing 
this sect, accepting without dispute the dogma of the 
four humoral qualities, together with the different 
temperaments which result from the predominance of 
any one of them, combated these different tempera- 
ments or constitutions by prescribing drugs in a very 
great variety of combinations (polypharmacy). 

The members of the second group or sect, the iatro- 
chemists, attaching small importance to simple 
dietetic measures, prescribed without stint all the 
most active substances belonging to the mineral 
kingdom and all the new remedies which the chemists 
had evolved from their furnaces. 

Finally, the iatrophysicists directed their efforts to 
the removal or diminution of all bodily conditions that 
appeared to act as mechanical hindrances to health. 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES sympathetic Ner.ou. 8y.u„ 



Sydenham, who was quick at perceiving the truth, 
and who possessed a rare degree of common sense, 
cast aside all these hypotheses as valueless, disre- 
garded the prevailing routine methods of treatment, 
and refused to accept the therapeutic novelties of the 
day. Nature is to be my guide, he declared, and 
from that time forward he studied disease at the 
bedside, and watched carefully, and with a mind free 
from prejudice, the effects of the remedies which he 
employed. Thus, pursuing the methods advocated 
by the great master Hippocrates, Sydenham was 
afjle to place his medical brethren once more on the 
pathway which leads to an increase in knowledge of 
the healing art. Practical medicine, which had pre- 
viously been falling into an almost moribund condi- 
tion, was by his efforts made again a living and grow- 
ing science. 

Sydenham's death from renal calculus, a gouty prod- 
uct which had tormented him through a period of 
over thirty years, occurred on Dec. 29, 1689. 

A. H. B. 



Sylvius, Franciscus. — (Latinized form of Frangois 
de le Boe). Born at Hanau, Prussia, of French parents 
in l(il4. He studied at various universities in France, 
Holland, and Germany, and finally obtained his 
medical degree at Basle in 16.37. He practised first 
at Leyden, delivering there lectures on anatomy, 
then in .\msterdam, returning finally to Leyden where 
he became professor of medicine at the University in 
1658. He was a practitioner and teacher more than he 
was an anatomist, yet it is as an anatomist that his 
fame persists, his name being given to various cerebral 
structures — aqueduct, artery, fossa, fissure, and ven- 
tricle. Sylvius was a follower in medicine, though 
not in anatomy, of the teachings of Paracelsus and 
belonged to the chemical school of medicine. He 
was a firm believer in the value of clinical instruction 
and gave daily lectures at the little hospital of twelve 
beds in Leyden. He was one of the first to insist upon 
the chemical nature of digestion and to recognize the 
action therein of the saliva. He was also one of the 
first to accept Harvey's newly promulgated doctrine of 
the circulation of the blood. He died in 1672 of a fever 
then epidemic in Holland. T. L. S. 



Sylvius, Jacobus. — (Latinized form of Jacques 
Dubois.) Born at .\miens, France, in 1478. He 
took up the study of medicine when near middle age, 
having been at first drawn to mathematics, and ob- 
tained his degree at the University of Montpellier 
in 1.528. He went to Paris in 1531 and taught anat- 
omy for many years at the College of Trinquet. 
later succeeding Vidus Vidius at the newly established 
College of France. Many of the anatomists of the 
following generation, including Vesalius, were his 
pupils. He did much to advance the knowledge of 
anatom}', especially describing and naming many of 
the muscles and blood-vessels of the bod.v, and is 
said to have been the discoverer of the valves of the 
veins; yet his contributions to science were small in 
comparison with what they might have been, taking 
into consideration his talent and his opportunities for 
study. The fault lay with himself, for he was of a 
narrow and prejudiced disposition, a fanatical follower 
of the teachings of Galen, and nurturing an invincible 
repugnance to dissection of the human body. He 
was coarse in speech, avaricious, and envious of all 
who had attained any eminence as anatomists or 
teachers. He died in 1555. The Sylvian ossicle 
(processus lenticularis). Sylvian valve (valvula vena> 
cava' inferioris), and caro quadrata Sylvii (musculus 
quadratus plants-) bear the name of Jacobus Sylvius, 
but the cerebral structures having this eponymic 
were named after Franciscus Sylvius of the century 
succeeding that of Jacobus. T. L. S. 



Syme, James. — Born at Edinburgh, Scotland 
Nov. 7, 1799. In 1821 he was chosen House Surgeon 
of the Royal Infirmarj- at Edinburgh. In 1823 he 
performed, for the first time in Scotland, an exartieu- 
lation of the hip-joint. (The case is recorded in the 
Edinburgh Medical and Surgical Journal, 1824.) 
.\bout this time he organized, in association with Dr. 
Mackintosh, a sort of private medical school, and 
here he began (1825) to give lectures on anatomy and 
surgery. Already in 1829 the number of those who 
attended his courses had reached a total of two 
hundred and fifty. In 1S33 he was chosen Professor 
of Clinical Surgery in the University, and in 1834 an 
.Attending Surgeon at the Royal Infirmary. In 1842 
he performed two operations to which." at a later 
period, his name was attached — viz., Syme's amputa- 
tion of the foot, and Syme's external urethrotomy. 
(The former is described in the London and Edin- 
burgh Monthly Journal of Medical Sciences, 1843. 
and the latter in the same journal for 1844.) In 1847 
he performed an exarticulation of the shoulder-joint, 
and at the same time ligated the subclavian arterj-, 
in a patient who was affected with an axillary aneu- 
rysm; and he obtained a successful result. He also, 
at this period of his career, extirpated the clavicle; 
this being the first time that the operation was per- 
formed in Great Britain. In 1848 he accepted an 
invitation to fill the Chair of Clinical Surgery at the 
University College Hospital. London, as the successor 
to Robert Liston, recently deceased. At the end of 
a few months, finding that the climate of London did 
not agree with him, he resigned his chair and returned 
to Edinburgh, where he was promptly restored to his 
former position of Professor of Clinic.Tl Surgery. In 
1861 ho was made Surgeon-in-Ordinary to the Queen 
whenever she might visit Scotland. In 1869 Oxford 
University conferred upon him the honorarj' title of 
Doctor of Laws. He died June 26, 1870. 

Of Syme's published writings the following deserve 
to receive special mention: "Treatise on Excision of 
Diseased Joints," 1831; "The Principles of Surgerv," 
1831 (third edition, 1842); "Case of Spontaneous 
Varicose .Aneurysm," 1831; "Fibrocartilaginous 
Tumor of the Humerus; Removal together with the 
.Arm and Part of the Scapula and Clavicle; Recoverv," 
1836; "On Diseases of the Rectum," 1838; "Contri- 
butions to the Pathology and Practice of iSurgery," 
1848; "On Stricture of the Urethra and Fistula in 
Perineo," 1849; and "Traumatic Aneury.sm of the 
Common Carotid, successfully treated by Incision 
and Ligature above and below the .Aneurvsm," 1857. 

"A. H. B. 

Sympathetic Nervous System. — Definition. — The 
autonomic or sympathetic nerve-system is that por- 
tion of the general ncrvc-sy.stem, which, in especial, 
governs and regulates the vegetative life. It consists 
of: (1) ganglia widely distributed centrally and per- 
ipherally, (2) connecting and communicating fibers 
which bring its several members into relation with 
one another, and with the centers, trunks, and periph- 
eral distributions of the cerebrospinal system, and 
(3) distributory fibers which innervate the autonomic 
tissues (glands, contractile cells, unstriated muscle 
fiber, wherever found, cardiovascular, respiratory, 
alimentary systems, etc.). It forms certain important 
chains and plexuses, and includes a number of mono- 
cellular ganglia chiefly peripheral. 

By some authors it is divided into two portions of 
supposedly antagonistic function, termed respectively 
sympathetic system proper and autonomic system proper, 
or sympathetic and parasympathetic. "The former 
term is applied to the flioracic and abdominal ganglia, 
together with their fibers of communication and 
distribution (thoracolumbar system). The latter term is 
applied to the craniobulbar (midbrain and hindbrain) 
and sacral ganglia, together with their fibers of com- 
munication and distribution (craniosacral system). 

61 



Synipalhdic Nf 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



The essential iinil of slructure consists of a ganglion 
(svnapse or relay station), a preganglionic fiber with 
its nucleus of origin, and a postganglionic fiber with 
its end-organ. . . 

The prego iiglionic fiber originates from a sjinpathet ic 
nucleus in the lateral gray matter of the spinal cord 
or in the gray of the cerebral cortex and terminates 
(commonlv by arborization) in a sjonpathctic gang- 
lion. Preganglit)nic fibers may pass through one or 
more ganglia without terminal arborization, before 
reaching tlieir end-ganglion. 

The iioxlganglioiiic fiber continues from tlie ganglion 
to the yiscus or tissue innervated. 

The enliric .sysUm of Liingleij, is sometimes included 
with the thoracolumbar system, and the whole 
entitled lliornconiilrid ai/mpathetic, but more commonly 
it is described separately. It consists of cells and 
fibers which are grouped together to form the plexuses 
of .Vuerhach and Meisner. The former is found be- 
neath the longitudinal layer of muscle from the unstri- 
ated portion of the esopiiagustothercctum. Within 
the submucous coat is the similar plexus of Meisner. 
They contain fibers from the solar plexus and both 
meduUated and non-mcduUated fibers from the sym- 
pathetic and spinal systems. The glandular peri- 
glandular and subepithelial ti-ssues, the blood-vessels 
and villi receive their innervation through distributory 
fibers of this system. Langlcy writes that the his- 
tological characteristics of the cells of this system 
(lillcr in some respects from the nerve cells of the 
vertebral and prevertebral ganglia; and that further- 
more it is doubtful whether connection with the 
cerebrospinal system is established by sympathetic 
or by parasympathetic (cranial and sacral) fibers. 
Hence he prefers to consider it as a different system. 

Anatomy. 

S«iPATHETic Ganglia. — The ganglia of the sym- 
pathetic nerve system are classified according to their 
anatomical situation as (1) vertebral (or chain) 
ganglia; (2) prevertebral (or plexus) ganglia; and 
(3) peripheral ganglia. 

The vertebral ganglia (ganglia trunci sympatheci) 
form the nodes in a symmetrically placed pair of chains 
or cords (trunci sympatheci) situated on each side of 
the middle line in front of or to the side of the bodies 
of the vertebra; (ventrolaterad), and extending from 
the base of the skull to the coccjtc, where they unite 
by finely twisted cords and merge in the single coccy- 
geal ganglion (ganglion impar). 

Each chain extends upward into the cranial cavity 
by means of a branch (internal carotid nerve) whicli 
forms a fine plexus along the internal carotid artery 
and the cavernous sinus, giving off filaments to com- 
municate with certain cranial nerves. 

The fibers making up the great cords connecting 
the ganglia in each chain are termed rami internodiales. 

Communication is established between the two 
chains by fibers termed rami interfuniculares; these 
are developed most abundantly in the lumbar and 
sacral regions. With the cerebrospinal nerve system, 
communication is brought about by fibers termed 
rami cornmunicarttas. 

There are two types of rami communicantes, 
termed respectively white and gray, accordingly as 
they contain meduUated (myelinated) or pale ("non- 
myelenie) fibers. In some instances the two are 
blended into one cord, composed of a white and a 
gray portion. 

A (/rag ramus communicans conveys sympathetic 
fibers to each spinal nerve (anterior division) and some 
of these fibers pass on in the trunk of the nerve and its 
various subdivisions, toward the periphery. 

The white rami (which transmit to the sympathetic 
both afferent and efferent fibers) issue from the spinal 
cord with the anterior divisions (primary) of the spinal 
nerves from the first thoracic to the first lumbar 

62 



nerve inclusive, and of the second third and fourth 
sacral nerves, the latter being in communication with 
the pelvic plexuses (prevertebral) of the sympathetic. 

Each gangliated chain is divided into four portions: 
(1) cervical or cervicocephalic, (2) thoracic, (3) 
lumbar, (4) sacral. 

The cervicocephalic portion of the sympathetic 
cord commonly contains three ganglia, a superior, 
an inferior, and a middle cervical ganglion. The 
absence of the latter is often noted, while some au- 
thorities classify the inferior cervical ganglion with 
the prevertebral chain. This portion of the cord 
receives no white rami communicantes but through 
the association cord receives its white spinal fibers 
from the upper thoracic nerves through their re- 
spective ganglia. 

The superior cervical ganglion, fusiform, of a reddish- 
gray hue, situated opposite the .second and third 
cervical vertebrx, and resting upon the rectus capitua 
anticus muscle, is the largest of the three. The in- 
ternal carotid artery lies anterior to it and the vagus 
nerve behind. Its communicating branches are di- 
vided into four groups (1) somatic, (2) visceral, (3) 
vertebral, (4) vascular. 

The somatic branches consist of four gray rami join- 
ing the anterior primary divisions of the first four 
cervical nerves. Communicating branches to the 
cranial nerves are given off as follows: (a) to the pet- 
rous ganglion of the glossopharyngeal, ib) to the vagus, 
(c) to the hypoglossal nerve, {d) to the external laryn- 
geal nerve. 

The visceral branches are, (a) the pharyngeal nerve 
to the pharyngeal plexus, (6) the superior cervical 
cardiac nerve to the cardiac plexus, (c) communicating 
fibers to the external laryngeal, middle cardiac and 
superior cervical cardiac branches of the vagus nerve; 
to the inferior laryngeal; and also fibers which enter 
into the substance of the thyroid gland. 

The vascular branches are (a) external carotid, and 
(b) internal carotid. 

The external carotid division furnishes filaments 
which accompany the artery of that name and its 
branches; also by way of the facial plexus a branch 
known as the sympathetic root of the submaxillary 
ganglion; and the smallest deep petrosal nerve, which, 
running from the middle meningeal plexus, is known 
as the sympathetic root of the otic ganglion. 

The internal carotid division, extending upward into 
the cranium beneath the artery of similar name, divides 
to form the carotid and cavernous plexuses. 

The carotid plexus is situated at the outer surface 
of the internal carotid canal at its second bend. It 
gives off filaments which accompany the terminal 
branches of the artery; also communicating fibers to 
the abducent nerve, the Gasserian ganglion and the 
great and small deep petrosal nerves. 

The cavernous plexus lies in relation to the caver- 
nous sinus, inferior and internal to the internal carotid 
artery. It gives off filaments to the oculomotor nerve, 
to the trochlear nerve, to the ophthalmic division of 
tlic trigeminal nerve, to the ciliary ganglion, and to the 
pituitary body. 

The vertebral branches are but two or three fila- 
ments whose ultimate distribution is to the vertebral 
bodies and ligaments of the upper thoracic spine. 

The middle cervical ganglion, when present, lies pos- 
terior to the carotid sheath in the neighborhood of the 
inferior thyroid artery. 

The somatic branches comprise gray rami, arising 
either from this ganglion or from its associated cord, 
joining the anterior primary divisions of the fifth and 
sixth spinal nerves. The subclavian loop {ansa suh- 
clavia, vel Vieussenii), is often a double nerve looping 
over the subclavian artery to join the inferior cervical 
ganglion. It gives branching fibers to the subclavian 
and phrenic arteries. 

The visceral branches, which arise from the associ- 
ated cord in the absence of the ganglion, go to the 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



Sympathetir Xertous Syatem 



thyroid plexus and accomijauy the inferior thyroid 
artery to the thyroid gland. Fibers are also sent to 
the middle cervical cardiac and deep cardiac plexuses. 

The inferior cerncal ganglion lies to the inner side 
of the superior intercostal artery opposite the base of 
the transverse process of the last cervical vertebra and 
the neck of the fir.st rib. It is probably formed from 
the coalescence of two ganglia corresponding to the 
last two cervical nerves. 

The somatic branches comprise the gray rami com- 
municantes, which are two non-meduUated fibers join- 
ing the anterior primary divisions of the seventh and 
eighth spinal nerves; tlie subclavian loop already de- 
scribed; and communicating fibers to the inferior 
laryngeal nerve. 

The visceral branches comprise the vertebral plexus 
situated upon the vertebral arteries, and the inferior 
cervical cardiac nerve to the cardiac plexus. 

Thoracic Cord.- — The thoracic portion of the sympa- 
thetic cord consists of ten to twelve small, grayish, 
irregularly triangular or fusiform ov.al ganglia, covered 
by the parietal pleura and situated lateral to the spinal 
vertebra?, resting upon the heads of the ribs. They 
are joined by an interassoeiation cord. A white and 
a gray ramus communicans connect each ganglion 
with its corresponding spinal nerve. 

The rami communicantes are arranged in two series. 
The upper five, coursing cephalad, are distributed by 
means of the cervicocephalic association pathways to 
the thoracic aorta, to the vertebral ligaments, and to 
the posterior pulmonary plexus. From the lower 
seven are derived the greater, lesser, and least splanch- 
nic nerves. Filaments are also distributed to the ab- 
dominal aorta. 

Somatic Branches. — By means of gray rami com- 
municantes which pass backward (one or more from 
each ganglion) communication is made with the an- 
terior primary divisions of the thoracic spinal nerves. 

The visceral branches are the gray splanchnic effer- 
ent and the white .splanchnic efferent and afferent 
fibers. The splanchnic afferent fibers have no sym- 
pathetic connections and consist merely of tracts 
which carry impulses from the splanchnic through the 
thoracic and spinal ganglia to the posterior roots of 
the spinal nerves. 

The splanchnic efferent fibers form two series. 
Those of the upper series are distributed mainly as 
branches of the cervical ganglia; those of the lower 
series within the thorax (6 to 12 thoracic nerve inclu- 
sive) supplying tlie aorta and lungs with vasomotor 
fibers. Below the thorax they supply in conjunction 
with the vagus, visceroinhibitory fibers for the gastro- 
enteric tract, motor fibers for the rectum, vasomotor 
fibers for the abdominal aorta and its branches, and 
secretory and sensory fibers for the abdominal viscera. 
The thoracic gangliated cord contains also many effer- 
ents of spinal-cord origin which join the nerves to the 
upper and lower extremities from the cervical and 
lumbosacral segments of the spinal cord. Thus the 
thoracic spinal nerves supply vasomotor, pilomotor, 
and secretory filaments not only for the upper ex- 
tremities but also for the greater part of the lower 
half of the body. 

Visceral Branches. — These comprise the pulmonary, 
aortic, and splanchnic nerves. The pulmonary 
branches are derived from the second, third, and fourth 
ganglia and join the posterior pulmonary plexus. The 
aortic branches are derived from the upper four or five 
ganglia and are distributed to the vertebrae and their 
ligaments and to tlic thoracic aortic plexus. 

The great splanchnic nerve arises by a series of 
roots from the gangliated cord from the fifth to the 
ninth ganglia inclusive, and descending along the 
anterior lateral aspect of the vertebral column, pierces 
the crus of the diaphragm and enters the semilunar 
ganglion. Some fibers are distributed to the supar- 
renal bodies and the renal ganglion (plexus). In its 
thoracic course is developed the great splanchnic 



ganglion, from which as well as from the nerve, fila- 
ments are distributed to the esophagus, thoracic 
aorta, and the vertebr.al bodies. 

The small splanchnic nerve is formed from fibers of 
the tenth or tenth and eleventh ganglia, or from the 
adjacent portion of the interassoeiation cord. It 
pierces the crus of the diaphragm and ends in that 
portion of the semilunar ganglion known as the aortico- 
renal ganglion. 

The least splanchnic nerve ari-ses from the last 
thoracic ganglion, pierces the diaphragm, and ends in 
the renal plexus. Sometimes a fourth splanchnic 
nerve is present. 

Lumbar Cord. — The lumbar sympathetic cord con- 
sists of four ganglia situated in front of the vertebral 
column along the inner margin of the psoas magnus 
muscle. 

The somatic branches comprise the gray and white 
rami communicantes. The white rami "are derived 
from the first, second, and third spinal nerves and join 
the upper portion of the ganglionic cord. They con- 
tain splanchnic, efferent, and afferent fibers which are 
distributed to the lower extremities, rectum, and gen- 
ito-urinary tract. The gray rami communicantes are 
inconstant in number and irregular in their method of 
passing to a spinal nerve. 

The visceral branches comprise filaments which 
pass to the aortic, hypogastric, and vertebral plexuses. 

Sacral or Peine Cord. — The sacral portion of the 
sympathetic cord usually consists of four small ganglia 
and their associated cord. There may be considerable 
variation in number and size. The ganglia are situ- 
ated anterior to the sacrum along the inner side of the 
anterior sacral foramina and are connected above with 
the lumbar chain, while they unite below in the gang- 
lion impar. While there are no white rami, the vis- 
ceral branches of the pudendal plexus, passing without 
a relay through a ganglion, directly to the plexus are 
considered homologous with white rami communi- 
cantes. White fibers reach the sacral portion of the 
sympathetic cord from the lumbar cord. 

The somatic branches comprise the gray rami com- 
municantes. They pass from the sacral ganglia to 
the anterior primary divisions of the sacral and coccy- 
geal spinal nerves. 

The visceral branches pass through the pelvic plexus 
to the rectum and genito-urinary tract. Parietal 
branches ramify in front of the sacrum, furnishing 
fibers to the sacrum, coccyx, and their ligaments as well 
as the coccygeal body. 

The Sympathetic Pre^-ertebral Plexuses. — These 
are the great way stations of the sympathetic system. 
They consist of groups of nerve cells forming minute 
ganglia, aggregations of smaller ganglia forming larger 
ones, and all of their intertwined filaments. The prm- 
cipal ones are situated in the thoracic, abdominal, and 
pelvic cavities. They are termed the cardiac, pulmon- 
ary, esophageal, solar^ and pelvic plexuses. 

The cardiac plexus is found at the base of the heart 
and is divisible into a deep and superficial plexus. 
The stiperficial cardiac pltxu.<< is the smaller and lies 
beneath the aortic arch in front of the pulmonary- 
artery. (The ganglion of Wrisberg lies in it-s mesh.) 
It is formed by the left superior cardiac nerve and the 
left inferior cervical cardiac nerve of the vagus and 
deep cardiac nerve. Joining the plexus is the supe- 
rior cervical cardiac branch of the left gangliated cord 
and the inferior cervical cardiac branch of the left 
vagus. Fibers are distributed to the right coronary 
plexus, the left half of tlie deep cardiac plexus, the left 
anterior pulmonary plexus. 

The deep cardiac plexus lies above the bifurcation of 
the pulmonary artery, posterior to the aortic arch and 
anterior to the lower end of the trachea. It is divis- 
ible into a right and left portion, united by inter- 
twining filaments around the lower part of the trachea. 
The right portion receives all of the cardiac branches 

63 



Sympsthetlr Nemous System 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



of the sympathetic, vagus, and inferior laryngeal 
nerves on" the right side. The left portion receives all 
of the cardiac branches of the left sympathetic, vagus 
and inferior laryngeal nerve and filaments from the 
superficial cardiac plexus. (The two branches which 
enter the superficial plexus are excepted.) 

The right or anterior coronary plexus is derived 
from the right portion of the deep cardiac plexus, and 
follows the course of the right coronary artery, supply- 
ing fibers to the artery, to adjacent portions of the 
heart and contributingfilaments to the superficial car- 
diac plexus and the right anterior pulmonary plexus. 

The left coronary plexus is derived from the left 
portion and has a similar course and distribution upon 
the left side. 

The solar plexus is the largest of the sympathetic 
plexu.ses. It is situated in the upper abdomen, pos- 
terior to the .stomach, anterior to the aorta and dia- 
phragm. Below is the pancreas, upon either side are 
the adrenals. Its meshes are situated around the celiac 
and superior mesenteric arteries. It is connected with 
all of the abdominal plexuses, and by means of the 
aortic and hypogastric plexuses is in communication 
with both pelvic plexuses. The right vagus and the 
great and small splanchnic nerves contribute to its 
formation. It is divisible into the semilunar ganglia 
and celiac plexuses. 

The .iriiiihinar ganglia lie upon the crura of the 
diaphragm .separated from each other by the celiac 
and superior mesenteric artery, close to the adrenals. 
They are the largest of the ganglionic components of 
the solar plexus. The two are connected by filaments 
which pass above and below the root of the celiac 
axis. The upper expanded end receives the great 
splanchnic nerve. The lower or the aorticorenal 
ganglion receives the small splanchnic nerve. A third 
portion is called the superior mesenteric ganglion and 
lies to the right of the origin of the superior mesenteric 
artery. Filaments emerge from the semilunar gang- 
lia connecting them with all of the derivative ganglia 
of the solar plexus. 

The cclinc plexus twines round the celiac axis and 
receives filaments from the right vagus and semilunar 
ganglia. It joins inferiorly with the superior mes- 
enteric and aortic plexuses. From it are derived the 
coronary, hepatic and splenic plexuses. 

The gastric plexus, accompanies the artery of that 
name along the lesser curvature of the stomach, in- 
osculates with both vagus nerves and distributes fila- 
ments to the deeper coats of the stomach. 

The hepatic plexus inosculates with the left vagal 
filaments and after coursing along with the bile duct, 
hepatic artery, and portal vein enters and ramifies in 
the liver. It sends filaments to the right suprarenal 
plexus and to the area of distribution of the hepatic 
artery. 

Other subsidiary plexuses of the solar plexus fol- 
low along the courses of the arteries so that the 
diaphragmatic, suprarenal, renal, superior and inferior 
mesenteric, spermatic and ovarian, splenic and aortic 
plexuses are named and recognized. 

The hypogastric plexuses are the continuation of the 
aortic plexuses and lie in the angle between the com- 
mon iliac arteries, on the posterior wall of the pelvis. 

The pelvic plexuses which are the terminal derivatives 
of the hypogastric plexu.ses and are situated lateral to 
the rectum and the vagina in the female, comprise fibers 
from the sacral cord and from the visceral branches 
of the pudendal plexuses. They distribute fibers to 
supply the pelvic organs, coursing along the internal 
iliac arteries and their derivations. Subsidiary plex- 
uses are the hemorrhoidal, vesical, prostatic, ■uterine, 
vaginal, and cavenunts plexuses. 

Cranial and other Peripheral Ganglia. — The 
peripheral ganglia lie in close relation with the organs 
and ti.ssues. They include the parasympathetic ganglia 
of the head described as component parts of the cranial 

64 



autonomic system, the intravisceral gangUa of the 
heart, the lungs, the stomach and intestinal walls, and 
the pelvic ganglia at the base of the bladder. 

The ganglia of the head, are in structure essentially 
the same as other autonomic gangUa and include the 
otic, the sphenopalatine, the ciliary and submaxillary 
ganglia. They bear to the cranial nerves, a like rela- 
tion to that of the vertebral and prevertebral ganglia 
with the spinal nerves. They are described as having 
three roots — sensory, motor, and sympathetic. 

The ciliary ganglion (ophthalmic) reddish and quad- 
rilateral, is situated in or near the apex of the orbit 
jjostcrior to the eyeball, and to the outer side of the 
optic nerve. 

The motor root is a branch of the oculomotor nerve, 
the sensory root is a branch of the nasal nerve and the 
sympathetic root is derived from the cavernous plexus. 
The short ciliary nerves are branches of this ganglion. 

The sphenopalatine (Meckel's) ganglion is small, red- 
dish gray, and lies in the upper portion of the spheno- 
maxillary fossa. 

The sensory root is formed by the sphenopalatine 
nerves, branches of the maxillary nerve. The motor 
root is the great superficial petrosal nerve, a derivate 
of the facial nerve, and the sympathetic root is the 
great deep petrosal nerve which in the middle lacer.ated 
foramen joins with the motor root to form the Vidian 
nerve. The sphenopalatine ganglion gives rise to four 
sets of branches, — ascending, descending, internal, and 
posterior. 

The otic ganglion (Arnold's) is small, irregularly 
oval, and lies to the mesial side of the mandibular 
nerve below the foramen ovale. The sensory root is 
derived from the small superficial petrosal nerves; 
the motor root is a branch from the internal ptyergoid 
nerve; the sympathetic root is derived from the middle 
meningeal plexus. It gives off branches to adjacent 
nerves, among them fibers which join the auriculotem- 
poral nerve to the parotid gland. 

The suhmaTillanj ganglion is a small reddish tri- 
angular ganglion situated above the deep portion of 
the gland. The sensory root is derived from the 
lingual nerve; the motor root from the facial nerve by 
way of the chorda tympani; the sympathetic root 
from the facial plexus. 

Other peripheral ganglia derive their names from 
their anatomical situations. 

Relations op the Autonomic Nerve System with 
THE Central Nerve System. — The cranial (cranio- 
bulbar) autonomic or parasympathetic system is sub- 
divided into a midbrain and a hindbrain system. 

The preganglionic fibers of the midbrain system 
arise from groups of nerve cells situated in the gray 
matter beneath the aqueduct of Sylvius prior to 
where it forms the third ventricle. They enter the 
orbital cavity by way of the inferior branch of the 
oculomotor nerve and here arborize around cells of 
the ciliary ganglion. From the cells of this ganglion 
gray posterior ganglionic fibers are distributed to the 
choroid, the ciliary muscle and the sphincter muscle 
of the iris, and some authorities state to the cornea as 
well. 

The preganglionic fibers of the hindbrain system 
arise from groups of nerve cells situated in the region 
of the calamus scriptorius beneath the floor of the 
fourth ventricle and pass out of the brain in company 
with the nerve of Wrisberg, the glossopharyngeal and 
the vagus nerves to terminate around cells of various 
ganglia. 

Those fibers which accompany the nerve of Wrisberg ' 
arc conveyed first through the facial nerve to the great 
superficial petrosal nerve through which they pass to 
the sphenopalatine ganglion, while some "of them 
enter the chorda tympani and pass to the submaxillary 
ganglion, in each instance arborizing around cells of 
the respective ganglia. From the cells of these gang- 
lia gray postganglionic fibers arise and are distributed 



REFERENCE HANDBOOK 

OF THE 

MEDICAL SCIENCES 



PLATE LVI 



Tub 



"^ff/e 



So/if ary-ff/ands 



crania/ muc. fnem. 



J/eorf 



p^ Vesseh o/ the Stomach 
and in testine 




^ancrfas 



^A/i/nei/ 



Sma/i/n tea fme 
and Cecum 



Co/on and /feci u/Ti 



G.pe/y. 



I\^__^ Genii a/s 



1)ia(;ram of thk Autonomic and Sympathetic Xkkvous Systems. (After Jfeyor and Gottlirbj 



REFERENCE HANDBOOK OF THE MEDIC.\L SCIENCES 



Sympathetic Nervous System 



to the blood-vessels and glanfls of the nose and mouth, 
and the blood-vessels and epithelium of the submaxil- 
lary and sublingual glands. Included in their distri- 
bution are the regions of the soft palate, uvula, tonsils, 
upper lip, upper gums, and upper portion of the 
pharynx. 

Those fibers which accompany the glossopharyngeal 
nerve are conveyed by the nerve of Jacobson to the 
otic-ganglion. From the cell of this ganglion gray 
postganglionic fibers arise and are distribued through 
the auriculotemporal branch of the 
trigeminal nerve to the mucous mem- 
brane and blood-vessels of the lower 
lip, lower gums, tlie cheek, and the 
lepithelium of the parotid gland. 

The preganglionic fibers which in - 
company the vagus nerve terminate 
around cells of the ganglia of the 
heart, .stomach, and small intestine. 
From the cells of these ganglia gray 
postganglionic fibers arise and arc 
distributed to the blood-vessels, the 
non-striated muscle fibers and the 
epithelium of the glands of the 
esophagus, stomach, intestine, tra- 
chea, bronchi, liver and biliary pas- 
sages, the pancreas and its ducts, and the kidney 
tubules. 

The preganglionic fibers of the snernl autonomic 
{parnsymiiiilhitir) system arise from cells of the 
nucleus sympathicus inferior and after entering the 
ventral roots of the second, third, and fourth sacral 
nerves accompany them into the pelvis. In the pelvis 
they accompany the pudendal nerve (nervus erigens) 
to arborize around cells of the pelvic ganglia. From 
the cells of these various ganglia, gray postganglionic 
fibers arise and are distributed eventually to the blood- 
vessels of the external generative organs and the non- 
striated muscle fibers of the pelvic viscera. 

THORACOLUirBAR SYSTEM OR SYMPATHETIC SySTEM 

Proper. — Sympathetic Nuclear Tracts. — In the spinal 
gray matter Jacobson distinguishes and names : (1) A 
nucleus sympathicus superior extending from the eighth 
cervical to the second lumbar segment and from 
whose cells arise all rami communicantes of the 
gangliated cord. (2) A nucleus sympathicus lateralis 
inferior extending from the level of the second lumbar 
segment to the end of the cord and from whose cells 
the pelvic nerve arises. 

These tracts together with the fine medullated 
nerve fibers which have their origin as described in the 
craniobulbar parasympathetic nerve system serve to 
bring the two systems into a close physiological and 
anatomical relationship. 

Thoracic Chain. — The preganglionic fibers have their 
origin in cells of the nucleus sympathicus superior and 
emerge in the ventral roots of the thoracic and upper 
lumbar spinal nerves. They pass to the vertebral 
chain ganglia through the white rami communicantes, 
leaving the ventral roots of the spinal nerv^es where it 
splits into an anterior and posterior division. By 
some authorities the preganglionic fibers of this system 
are classified according to their distribution into 
thoracic and lumbar groups. 

The thoracic group, comprises five sets of fibers: 

1. Fibers leaving the spinal cord with each thoracic 
nerve and which end around ganglion cells of the same 
level. 

2. Fibers leaving the spinal cord with the fourth to 
the tenth thoracic nerve and turning upward in the 
vertebral chain to end around ganglion cells of the 
stellate or first thoracic ganglion. 

3. Fibers leaving the spinal cord with the second 
and third thoracic nerve and which also turn upward 
in the vertebral chain to end around cells of the inferior 
cervical ganglion. 

4. Fibers which leave the spinal cord with the sec- 

VoL. VIIL— 5 



ond, third, and often the fourth .spinal nerve and which 
pass upward in the vertebral chain without termlnat- 
mg, through all ganglia until reaching the superior 
cervical ganglion around the cells of which they 
arborize. 




Fig. 4717. — Diagram of the Structural luterrelatioa bctw 
Cerebrospinal and Sympathetio Systems. 



Cerebrospinal neurones of centrifugal f unctiona. 

Cerebrospinal neurones of centripetal function*. 

-■ Jpt = .Sympathetic neurones of centrifuKal functions. 

'J' = Sympathetic neurones of centripetal functions. 

A = .Spinal ganglion cell of the second type of Dogiel. 



5. Fibers which leave the spinal cord with the fifth 
to the tenth thoracic nerve and pass into the gangli- 
ated chain, running downward and forward to the 
levels at which thev merge to form the greater and least 
splanchnic nerves! The cells of the semilunar renal 
and superior mesenteric ganglia receive the terminal 
filaments of this division. 

65 



Sympathetic Nervous System 



REFERENCE HANDBOOK OF THE MEDIC.JlL SCIENCES 



Tlip Itunlmr (jrnup of preganglionic fibers comprise 
thret' (lifTorent sets: 

1. Fibers which follow a pathway like the preced- 
ing set and which end around ganglion cells of the 
same level. ... , 

2. Fibers which pass into, and cross the chain and 
run forward to merge into the inferior splanchnic 
nerves. The cells of the superior inferior mesenteric 
ganglia receive their end arborizations. 

3. Fibers which pass into and downward in the 
chain to end around cells of the chain nunglia at the 
level of the third sacral ganglion. Fillers from the 
lower thoracic nerves may at times puss downward in 
the lumbar chain. 

Postganglionic Fibers of the Thoracolumbar {Sympa- 
thetic) System. — From the cells of the various verte- 
bral and prevertebral ganglia with which the [iregang- 
lionic fibers come into relation, postganglionic fibers 
arise which are distributed to non-striated vascular 
and visceral muscle fiber and to the epithelium of 
glands in all portions of the body, principally as 
follows: 



Spmal 



Symfial/tetti 
ChatTt 



a. /".V-i^-j/ 


t.c /,l. 


< ^ 


i : ^ 




1 ^^-^ 



<^^ 



■Ns?; 



Fio. 4718.— Diagram Showing Va 
between Spinal Cord, Ganglia, 



ious Methods of Connecti( 
nd Periphery. (Langley.) 



The postganglionic fibers of the thoracic grnu-p, aris- 
ing from ganglion cells of the same level supply the 
blood-vessels and glandular epithelium of the sweat- 
glands of the skin of the ann, trunk, and body. 

The postganglionic fibers from the stellate ganglion 
supply the blood-vessels and sweat glands of the skin 
of the arm (in conjunction with the inferior cervical 
postganglionic fibers), and al.so sends fibers to merge 
with the sympathetic cardiac ner\'es from the inferior 
cervical ganglia. 

The postganglionic fibers from the inferior cervical 
ganglion help to supply the blood-vessels and sweat- 
glands of the skin of the arm; fibers which are often 
termed the sympathetic cardiac fibers and which in- 
nervate the heart muscle. Fibers from the first thor- 
acic ganglia sometimes merge with them. 

The postganglionic fibers from the superior cervical 
ganglia supply the blood-vessels and glandular epi- 
thelium of certain regions of the head and face in 
association with branches of the facial nerve. Other 
filaments link with fibers from the middle and inferior 
cervical ganglia helping to form the cardiac plexuses. 
The postganglionic fibers from the semilunar, renal, 
and supi'rior mesenteric ganglia interlace with one 
another to form the solar plexus which in turn 
is divided into numerous subsiduary plexuses as 
mentioned previously. The end fibers innervate 
non-striated muscle fiber of the blood-vessels of the 
stomach, liver, adrenal, and small intestine, the 
muscle walls of the stomach, small intestine, gall- 
bladder, and the fibers of the sphincter, pylorus, and 
ileocolic junction. 

66 



The postganglionic fibers of the lumbar group, 
which arise from ganglia situated at the same level, 
supply fibers to the skin of the blood-vessels of the 
hip and leg as well as sweat-glands, in conjunction 
with fibers from the upper sacral region. 

The postganglionic fibers from the inferior mesen- 
teric ganglia in association with fibers from the superior 
mesenteric ganglia as well, innervate the muscle 
walls of the bladder, uterus, vagina, and colour and 
the muscle fibers of the blood-vessels of the pelvic 
viscera. 

The postganglionic fibers from the upper sacral 
ganglia innervate the blood-vessels of the skin of 
the hip and leg and the epithelium of the sweat-glands 
in this region. 

Physiology. 

Functions of the Midbrain Autonomic (Para- 
sympathetic) Syste.m. — The preganglionic fibers of 
this system arborize around cells of the ciliary gang- 
lion. The postganglionic fibers innervate the ciliary 
and sphincter pupillai muscles. Stimulation of 
either preganglionic or postganglionic fibers causes 
an augmentation of tonus or an increase in the 
degree of contraction of the sphincter pupilla and of 
the ciliary muscle. 

Functions op the Bulbar Autonomic (Para- 
sympathetic) System. — The preganglionic fibers asso- 
ciated with the nerve of Wrisberg and the facial nerve 
communicate by pathways already described with the 
sphenopalatine, submaxillary, and sublingual ganglia. 
Another group associated with the glossopharyngeal 
nerve arborize around cells of the otic ganglion; 
while a third group associated with the vagus nerve 
terminate around cells of the various peripheral 
ganglia mentioned in the anatomical description. 

Stimulation of the group of fibers associated with 
the sphenopalatine ganglion and its branches causes: 
(1) An inhibition of the contractile power of the 
blood-vessels of the mucous membrane of the nose, 
soft palate, upper lip, upper portion of the pharynx 
and the roof of the mouth. (2) An increase of the 
activities of the secreting epithelium of the mucous 
glands located in that region. 

Stimulation of the fibers associated with the 
submaxillary and sublingual ganglia causes: (1) An 
inhibition of the contractile power of the blood-vessels 
of the submaxillary and sublingual glands. (2) An 
increase of the secretory action of the epithelium of 
these glands. 

Stimulation of the preganglionic and postganglionic 
fibers associated with the otic ganglion causes: (1) 
An inhibition of the contractile power of the blood- 
vessels of the parotid gland. (2) An increase of the 
secretory action of the epithelium of the parotid 
gland. 

Stimulation of the preganglionic and postganglionic 
fibers associated with the vagus nerve gives rise to 
various phenomena determined by the terminal 
ganglia: (1) An inhibition of tonus and contractile 
power of the heart muscle. (2) An inhibition (but 
sometimes augmentation) of the contractile power 
of the muscle fiber of the esophagus and of the 
sphincter cardiae. (3) An inhibition of tonus of the 
cardiac end of the stomach. (4) An inhibition of the 
sphincter muscle of the common bile duct. (.5) An 
augmentation of the contractile power and tonus of 
the muscle fiber of the stomach, of the sphincter of 
the pylorus, of the visceral muscle in the walls of the 
gall-bladder, of the visceral muscles in the walls of 
the small intestines, and of the muscle fiber in the 
walls of the bronchi. (Occasionally an inhibition of 
the latter fibers is brought about.) (6) An augmenta- 
tion (occasionally an inhibition), of the secretory 
action of the epithelium of the glands of the stomach 
and pancreas. 



REFERENCE HANDBOOK OF THE MEDIC.U, SCIENCES 



Sympathetic Nervous System 



Functions of the Sacral Autonomic (Parasym- 
pathetic) Nerve System. — The preganglionic fibers 
of this system are associated with the peine ganglia. 
Stimulation of the postganKlionie fibers causes: (1) 
An inhibition of tonus of the blood-vessels of the 
generative organs, causing vascular dilatation. (2) 
An inhibition of tonus of the sphincter of the 
bladder. (3) An augmentation, during micturition, 
of the contractile power of the detrusor muscle. (4) 
An augmentation of the contractile power of the 
muscle wall of the colon and rectum and of the rectal 
sphincters. 

Functions op the TnoRAcoLUiraAR Autonomic 
(Sympathetic)_ System. — The specific functions of 
the fibers of this system are determined by the tissues 
of the body to which they are distributed and the 
ganglia from which the postganglionic fibers arise. 
Stimulation of the thoracic fibers which terminate 
in chain ganglia at the same level causes, in correspond- 
ing regions: (1) An augmentation of tonus and de- 
gree of contraction of "the blood-vessels of the skin 
of the arm, trunk, and body, and (2) an increase in 
the activities of the epithelium of the sweat glands. 

Stimulation of the fibers which terminate in the 
stellate and inferior cerincal ganglia, causes: (1) An 
acceleration of the rate and force and contraction of 
the heart muscle. (2) An increase in the activities 
of the secreting epithelium of the thyroid gland. 

Stimulation of fibers which terminate around cells 
of the superior ceri'ical ganglion causes: (1) An aug- 
mentation of tonus and degree of contraction of the 
blood-vessels of the skin and of the mucous membranes 
in the head, face, and neck, and of the blond-vessels 
of the submaxillary, sublingual, and parotid glands. 
(2) An increase in the activities of the epithelium of 
the sweat glands of the head, face, and neck, and per- 
haps of the salivary glands. (3) An augmentation 
of the tonus and contractile power of the dilator 
pupilla; muscle. 

Stimulation of the fibers associated with the splanch- 
nic nerve and the semilunar and solar plexus ganglia 
causes : (1) An augmentation of the tonus and contrac- 
tile power of the walls of the blood-vessels of the 
stomach, and intestines as far as the descending colon, 
of the blood-vessels of the kidney and spleen, of the 
muscle walls of the gall-bladder, of the sphincter at the 
ileocolic Junction. (2) An inhibition of the tonus and 
a diminution of the contractile power of the muscle 
fibers in the wall of the stomach and intestine, and of 
the sphincter muscle of the common bile duct, during 
digestion. (3) An increase in the activity of the 
secreting epithelium of the adrenal glands. 

Stimulation of the lumbar fibers, which terminate 
in chain ganglia of the same level, causes: (1) An 
augmentation of the degree of contraction of the 
blood-vessels of the skin of the trunk to which they 
are distributed. (2) An increase of the activities of 
the secreting epithelium of the sweat-glands in the 
corresponding regions. 

Stimulation of the fibers associated with the inferior 
splanchnic nerves and the inferior mesenteric and 
hypogastric ganglia, causes: (1) An inhibition of the 
tonus and contractile power of the muscle wall of the 
large intestine, and of the muscle walls of the bladder 
during micturition. (2) An augmentation of the tonus 
and contractile power of the blood-vessels of the 
pelvic viscera (of the uterus in particular), and of the 
sphincter rnuscle of the bladder. 

Stimulation of the fibers associated with the lower 
lumbar and tlie sacral (sympathetic) ganglia, causes: 

(1) An augmentation of the degree of contraction 
of the blood-vessels of the skin of the hip and leg and 
in the region of the external genitalia. (2) An increase 
in the activities of the secreting epithelia of the 
sweat-glands in the corresponding regions. 

Effect op the Emotions upon the Autonomic 
Nerve System. — As a result of his painstaking re- I 



searches upon the effect of emotion in man and animals 
Cannon has advanced interesting views concerning the 
relations between the endocrine glands and the vege- 
tative nerve system, and their mutual reaction under 
emotional excitement. 

He emphasizes the facts that the parasympathetic 
system has a restricted distribution while the sympa- 
thetic system is di-stributcd widely, and that the 
extremities of the autonomic system (cranial and 
sacral) are antagonistic in action to the midautonomic 
(thoracolumbar) in whatever viscus they happen to 
meet. Emotions gain expression through discharges 
along the neurons of the autonomic system and give 
rise to secretory — especially endocrine— vascular and 
muscular responses. Those emotions which manifest 
themselves in the momentarily dominant division of 
the autonomic system, also for the moment hold the 
field in consciousness. Any function may be dis- 
turbed, i.e. reinforced or abolished by either pleasure- 
able or painful emotions, according to the needs and 
life history, phylogenic and ontogenic, of the animal 
affected. Excess, deficiency, or inappropriate reaction 
results in accident, death, or disease. 

Cannon considers the cranial parasvmp.ithetic 
system as a builder up and fortifier of the bodily re- 
serves and cites as examples (1) that it shields the 
retina from light, (2) that it .slows the heart muscle, 
permitting rest and reinvigoration, (3) that it regulates 
the normal processes of digestion, enabling the body 
tissues to fortify themselves. 

The sacral parasympathetic system he considers as 
a group of mechanisms for emptying (i.e. defecation, 
urination) and a servant of racial" continuitv, because 
the end of the sexual act is due to discharges along 
sympathetic neurons. 

The sympathetic system is considered as the pre- 
server of the individual. Normally it dominates the 
bodily economy and holds therefore the field in con- 
sciousness. Only when emotions give rise to over- 
whelming parasympathetic excitation does it yield the 
field to its opponent. 

Regeneration op the Fibers of the Autonomic 
System after Section. — Langley found that after 
section of the preganglionic fibers, connection was 
reestablished with their ganglion cells. Each individ- 
ual fiber of the common trunk refound its cut-off por- 
tion, and after regeneration of the common trunk, 
stimulation of the trunk, or of the individual pre- 
ganglionic fibers excited the same physiologic response, 
as stimulation before section. This power of reforming 
connection, Langley, assumed to be of chemiotactic 
nature. 

An attempt was made by Langley to determine the 
possibility of having preganglionic fibers of one type, 
(parasympathetic) form connection with ganglia of 
the other typo (symp.ithetic). He divided the vagus 
and the cervical sympathetic at the same level in the 
neck. The periplieral end of the sympathetic was 
joined with the central end of the v.igus. A month 
later the connection with the superior cer\'ical gang- 
lion was established. He also joined the central end 
of the lingual with the peripheral end of the cervical 
sjrmpathetic. Stimulation of either hybrid nerve 
caused all the effects produced by stimulation of the 
sympathetic prior to the experiment. He concludes 
that "the fibers of the vagus and of the lingual nerve 
must in their respective cases, change their functions." 
With this view Timmc disagrees. He believes, as 
does the majority, tliat the function of any nerve 
fiber is simply conduction, and that the character of 
the end organ of the nerve determines the nature of its 
response to stimulation. 

The VEOETATn-E System and the Internal Secre- 
tions. — .\11 observers recognize that one of the most 
important functions of the autonomic nerve system 
is to preside over the activities of the endocrine glands, 
retarding or accelerating, increasing or diminishing 

67 



STmpatbetIc Nerrous System 



REFERENCE HANDBOOK OF THE MEDIC.\L SCIENCES 



their secretions in order to meet the demands of the 
body. As Sajous has so thoroughly shown, the bal- 
anced relations of the internal secretions is necessary 
to normal nutrition, growth, development, and vis- 
ceral function as well as to the maintenance of normal 
resistance to infection. Certain authors, among 
whom Eppinger, Falta, and Rudinger may be cited, 
believe that the thyroid and chromatline system, to- 
gether with the infundibular portion of the hypophysis 
cerebri (Berterelli), constitute a group of vascular 
glands which augment and accelerate the processes of 
destructive metabolism. The pancreas and para- 
thyroids, the anterior portion of the pituitary, to- 
gether with other similar vascular glands maintain 
the balance, promote anabolism, and retard catabol- 
ism. Furthermore, it is known that the group which 
promotes destructive metabolism has a sympathetic 
innervation and stimulates the sympathetic nerves, 
while exercising an inhibitory effect upon the para- 
sympathetic nerves. The group which retards c.itabol- 
ism or promotes anabolism possesses parasymp.'i- 
thetio innervation and stimul.ates the parasympathetic 
nerves, while exhibiting an inhibition of the sympa- 
thetic nerves. This subject is considered at length 
elsewhere in this HANnnooK and we need only point 
out the fact that a fault in the proper functioning of 
either group of glands, or any gland in the group, or 
in the functioning of either division of the autonomic 
system, will give rise to a fault in the proper function- 
ing of the other division or glands or groups of glands. 
Deficiency may lead to deficiency from want of 
normal excitation, or to excess from want of normal 
inhibition or from overcompensation. Conversely, 
excess may result in antagonistic or supplementary 
excess or deficiency. Each case and instance requires 
special study. 

Thyroid Gland. — The thyroid gland possesses both 
a sympathetic and a parasympathetic innervation. 
Therefore it affects both systems. Its principal effect 
is a stimulation of the .sympathetic system and it seems 
to sensitize the terminal organs to adrenalin. 

Adrenal Gland. — The secretion of the medullary 
portion of the adrenal is known as epinephrin or 
adrenalin. It is a sympathetic stimulant and its nor- 
mal activity is necessary for the proper functioning of 
the sympathetic .system. 

The secretion from the cortex is supposed to have an 

opposite action to that from the medullary substance. 

Thymus Gland. — Not much is known about the 

action of the secretion from the thymus gland. It is 

supposed to be a parasympathetic depressant. 

Fancrcas. — The production of the secretion of the 
pancreas .seems to be dependent upon the parasym- 
pathetic system. It not only influences sugar metabo- 
lism but in part the absorption of nutrient material 
(Biedl). It stimulates the inhibitory center govern- 
ing sugar production and has an inhibitory effect 
upon the stimulatory center. 

Pineal. — The secretion of the pineal body is sup- 
posed to have an antagonistic effect to that of the 
mfundibular portion of the hypophysis. Therefore, 
it would have an effect opposed to that of adrenalin 
upon the sympathetic. The effect is a mild one, and 
not much is known concerning it. 

Hypophtjjds. — From the posterior part pituitrin 
(hjT)ophysin) is derived. This substance has an 
effect upon the sympathetic system similar to that of 
adrenahn but less marked and more persistent. It 
increases the tonus of the intestine and the sensibility 
of the parasympathetic nerves to the bladder and the 
sympathetic nerve to the uterus. 

ParathijToids. — The secretion of the parathyroids be- 
sides being concerned in the calcium metabolism is 
supposed to have an inhibitory effect upon the sym- 
pathetic. 

Ovaries {corpus luteum), testicles, and other genera- 
tive organs are all supposed to be secreting organs. 
Little is known concernmg the action of their respect- 

68 



ive secretions upon the autonomic system, as experi- 
mental data, sufficient for definite conclusions, are not 
at hand. Clinically the secretions from the female 
generative organs {i.e. corpus luteum extract, ovarian 
extract, etc.) tend to relieve the autonomic ataxia of 
the menopause; hence they may be supposed to assist 
in preserving the autonomic balance during active 
sexual life. 

It is tentatively advanced by some writers that 
there exists in the body an exciting agent or hormone 
which presides over the production and activity of all 
the internal secretions, correlating the functions of the 
various endocrine glands through their vegetative 
innervation. For this hypothetical substance the 
name of "auionomin" has been suggested. 

Pharmacology of the S^-mpathetic akd Paras^-mpa- 
THETic NEmrE Organs. — Recently through the experi- 
mental researches of Meyer and Gottlieb and other 
observers certain drugs have gained prominence as 
excitors and depressants of the parasympathetic and 
sympathetic nerve systems respectively. These 
drugs act either centrally or upon the peripheral 
end organs of the postganglionic fibers. With the 
exception of nicotine which affects both systems alike 
they apparently elicit definite and antagonistic re- 
sponses, i.e. those which excite the parasympathetic 
inhibit the sympathetic and vice versa. This is espe- 
cially noted in organs and tissues receiving a double 
innervation, one set of fibers coming through parasym- 
pathetic (cranial and sacral), pathways and one set of 
fibers coming through sympathetic (thoracolumbar) 
pathways. For example (as described under Physio- 
logy) the efferent fibers of the vagus {parasympathetic) 
augment the contraction of the walls of the intestine 
while the efferent fibers in the splanchnic nerve 
{sympathetic), are inhibitory. The heart is acceler- 
ated by the sympathetic (re. accelerans) and inhibited 
by the vagus; the pupil is dilated by the sympathetic 
and contracted by the {parasympathetic) oculomotor 
nerve; the salivary secretions are inhibited by the 
sympathetic and increased by the parasympathetic. 

Because of these reactions the conclusion is drawn 
that the parasympathetic is not only the normal 
physiological antagonist of the sympathetic system 
throughout, but also that it invariably responds in an 
inverse manner to the same drugs. Going still further, 
and basing themselves upon clinical manifestations as 
well as the pharmacological and physiological re- 
sponses of both systems, Eppinger and Hess describe 
individuals of "vagotonic" and "sympathicotonic" 
constitution, in which one or the other system is of 
persi.stently exaggerated tonus. 

While admitting the antagonistic physiological 
response to stimuli, Brubaker caUs attention to the 
fact that the central nerve cells from which the pre- 
ganglionic fibers of the sympathetic system arise, m.iy 
lie in regions distant from their thoracic emergence, 
and often in the same regions as the central cells of tlie 
preganglionic fibers of the parasympathetic system 
running to the same viscus or organ. Thus, for exam- 
ple, the vasodilator and the vasoconstrictor centers 
for the salivary glands and the accelerator and vagus 
centers for the heart lie close together in the bulbar 
region. Therefore he writes that "the difference in 
the effects observed following stimulation of the two 
classes of nerves depends upon the character of tlicir 
peripheral terminations rather than in the difference of 
the character of their central cells," and that "there 
is no need for the employment of new terms." 

Huber, after a minute study of autonomic ganglia 
together with their constituent neurons, the termina- 
tions of the neuraxes in the various tissues, and their 
connections with the neurons of the cerebrospinal 
axis by means of the preganglionic fibers, states tliat 
"minor structural differences, do not warrant a regional 
subdivision of the autonomic system, when considered 
from the viewpoint of structure." 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



Sympathetic Nervons Srstem 



Griinwald, in discussing the pharmacological and 
chemical reactions of the parasympathetic and sym- 
pathetic systems as well as their end organs, assumes 
that similar pharmacological, which is to say similar 
chemical, reactions of organs indicate a similar chem- 
ical structure, and such may be assumed for all the 
sympathetic and parasympathetic terminal nervous 
organs, and that the centers of these two classes of 
nerves are characterized by certain chemical and phar- 
macological reactions which are characteristic of each. 
Jonescu, however, states that while parasympathetic 
centers exhibit the same chemical reactioiis this may 
not be said of the sympathetic central organs with the 
same general application, until there are more facts 
at hand to support that assumption. 

Langley has shown that both systems react in a 
constant manner to nicotine, which after a brief pre- 
liminary stimulation, interrupts the conduction path- 
way at the synapse or relay station. 

There is no exception to this rule, no matter what 
the character of the postganglionic fiber or the type of 
impulse that it conveys. By exposing the ganglion 
and painting it with a 6.. 5 per cent, solution of nicotine 
and then stimulating centrally to the ganglion he was 
enabled to determine whicji fibers simply passed 
through the ganglion in question, and which fibers 
arborized around its cells. The systemic action of 
nicotine likewise inhibits the effects of stimulation of 
the preganglionic fibers but does not prevent the usual 
response to postganglionic stimulation. It poisons, 
therefore, the relay station only. 

Pilcher and Sollmann are of the opinion that nicotine 
causes an intense stimulation of the vasomotor center. 
Discussing the view that the pressor effect of nicotine 
is due to central stimulation, R. G. Hoskins and S. W. 
Ransom believe from their experiments that it is due 



about half to a stimulation of the va.soconstrictor 
center proper and half to a stimulation of the gang- 
lion nerves. 

The following table arranged by Timme is 

mstructive. 



Autonomic Central Excitant Picrotoiin 

Autonomic Central Depre-isant . , . . Botulismua Toxin 
Sympathetic Central Excitants 
Sympathetic Central Depressant 
Autonomic Ends react to 



Cocaine, Atropine, Caffeiii 
Tetrahydronaphthalin. 



Choline Croup, PhysostiK- 
mine. Muscarine, Pilocarpine. 



Autonomic Ends Paralyzed by 

Sympathetic Ends React to Ad 

Sympathetic Ends Paralyzed by. , . Unknown. 

The following table compiled by Eppinger and Hes.s 
illustrates the correspondence between the action of 
adrenalin, atropine, and pilocarpine respectively upon 
the sympathetic and parasympathetic system.s, with 
the effects of electrical .stimulation of those sy.stems. 

It will be noticed that adrenalin acts in nearly equal 
degree upon all organs having a sympathetic innerva- 
tion and produces effects similar to those of electric 
excitation of the sympathetic. 

Pilocarpine has a more powerful excitant action 
upon certain portions of the parasympathetic sy.stem 
than upon others and produces effects similar to'those 
produced by electric excitation of the craniosacral 
system. 

Alro-pine modifies or abolishes the efiFects of cranio- 
sacral stimulation but exercises most of its paralysant 
action upon the cranial-parasympathetic system, and 
least of all, if any, upon the pelvic nerve. 

Muscarine has an action similar to that of pilo- 
carpine, but exhibits a somewhat different selectivity, 



EfTect of stimula- 
tion of the sympathetii 



Pilocarpine. ErgotoxiD 



Action of stimula- 
tion of the auto- 
nomic system. 







Stim. Th. I-II 








Stim. Th. I-III 








Stini. Th. II-IV 






Constrict. Th. II-IV 


Constriction (?) 


Constrict. Th. H-L. IV. . . 




Constrict. L. I-IV 




Stim. Th. II-L. IV 

Stim. Th. IV-VII 


Inhibition 



Stim. Th. I-V 

Relax. Th. II-V 

Para. Th. II-L. IV 

Diminished Th. II-L. IV. 

Para. Th. II-L. IV 

Diminished? 

Inhibition Th. II-L. IV... 

Relas. L. I-IV 

Relax. L. I-IV 

Relax. Th. II-L. IV 

Inhib.? 



Stimulation 
Relaxation 
Paralysis 
Diminished 



Contract. L. I-IV. 
Relax. L. I-IV.... 



Diminished 

Paralysis 

Relaxation 

Relaxation 

Relaxation 

Inhibition 

Inhibition 



Contract. L. I-IV 

Increases (Piqiire of CI 

Bernard) 

Increases (Piqftre Vermis), 
Contract 



Stimulation 
Stimulation (?) 

Constriction 

Dilatation 

Constriction 

Dilatation 

Constriction 

Constriction 

Inhibition 

Stimulation 

Stimulation 
Relaxation 
Paralysis 



Paralysis 

Diminished (?) 

Paralysis 

Relaxation 

Relaxation 

Relaxation 

Inhibition 

Inhibition 

Contraction 

Relaxation 

Contraction 

Relaxation 

Contraction 

Raised 
Raised 
Contraction 



Sphincter iridis 
Dilator iridis 
Ciliary muscle 
Orbital muscle 
Salivary glands 

Cortical blood-vessels 
Buccal blood-vessels 
Skin blood-vessels, head 

region 
Coronary blood-vessels 
Intestinal blood-vessels 
Genital blood-vessels 
Sweat glands 
Pilomotor muscles of the 

face I 

Heart muscle 
Esophagus I 

Cardia 

Gastric tone I 

Gastric peristalsis I 

Gastric secretion j 

Small intestine peristalsis' 
Colon 

Sphincter ani (muscle) 
Gall-bladder 
Pancreatic secretion 
Bronchial muscle 
Sphincter vesicie 
Detrusor vesicEB 
Uterus 
Uterus 
M. retractor penis 

Carbohydrate t. 
Heat balance 
Pigment cells 



Stimulation 

Paralysis 

Stimulation 



Inhibition 

Stimulation 

Stimulation 

Increase 

Increase 

Increase 

Stimulation 

Stimulation 

Spasm 

Contraction 

Stimulation 

Stimulation 



Relaxation 
Contraction 



Diminished 
Dilatation 



Stim. N. Ill 



Ch. tympani. se 

cretion 
Dilatat. N. X. 
Constrict. N. IX. 



Dilatat. N. pelv 



Inhib. N. X. 
Stim. N. X. 
Stim. N. X. 



N. X. 



Increases N. X. 
Increases N. X. 
Stim. N. X. 
Stim. X. pelvicus 
Spasm N. pelvicus 
Contract. N. X. 
Stim. N. X. 
Stim. N. X. 
Relax. N. pelvicus 
Contract. N. pelv. 



Relax. N. pelv. 



69 



Sympathetic Nervous System 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCKS 



acting more powerfully upon those parasympathetic 
nerves which innervate the heart. 

Picroldxin stiiniihites all the cranial and sacral 
autonomic (parasympatlietic) nerves but its action is 
central and not peripheral. 

Physosligmine increases the irritability of the auto- 
nomic end-organs, sensitizing them to other stimuli, 
and thus augmenting the response; in other words, it 
lowers the threshold. 

A drug which entirely paralyzes the sympathetic 
end-organs is at present unknown, though according 
to Dale, ergotoxin, "exhibits a slight selectivity for 
certain sympathetic nerve endings, the stimulation 
of which "causes motor activity, wiiile it produces no 
effect upon those causing inhibition." Pilcher and 
SoUmann write that ergotoxin has no effect on the 
vasomotor center. 

It must be remembered, liowever, and especially in 
connection with the circulatory, and in particular the 
vasomotor ajjparatus, that the apparent clinical re- 
sults following the administration of any one drug, 
are not the same throughout the whole body; the dif- 
ference depending largely upon the nature of the 
vasomotor supply of the particular tissue concerned. 
Thus, the nitrites, which dilate most of the arteries, 
constrict the pulmonary artery, and on the other 
hand, epinephrin, a general constrictor, dilates the 
coronaries. 

Certain drugs, moreover, show a tendencj[ to act 
specifically on one, rather than another, division of 
tlie vasomotor arterial supply; as, for example, 
yohimbine, which produces an active and specific 
vasomotor dilatation in the pelvic viscera . Other 
drugs act chiefly upon the vasomotor center or the 
vagus center. Thus it is now known that the effects 
of digitalis in slowing the heart and interrupting con- 
ductivity, arc due chiefly to stimulation of the vagus 
center, and I'ilchcr and Sollmann have recently made 
a study of drugs acting upon the vasomotor center 
which makes it necessary to revise some previously 
held opinions. This is not the place to discu.ss the 
matter fully, but it is necessary to warn our readers 
against premature conclusions on a subject so com- 
plex and subject to so many disturbing factors. 

Disorders of the Autonomic System. 

Those pathological conditions of the autonomic- 
sympatlu'tic nerve system which take the form of or- 
ganizc<t syndromes, or are related to definite lesions 
of glandular or other structures, as Raynaud's disea.se, 
Graves's syndrome, urticaria, hay fever, etc., are dis- 
cussed in this H.wnnooK under their respective syn- 
drome or pathological titles and need only mention 
here. 

The functional disorders of the autonomic sy.stem 
are chiefly paroxysmal in their manifestations and are 
commonly accompanied with pain, often with swelling 
and discoloration or pallor. They divide themselves 
into two great groups; in one the disturbances are 
varied and multiform; in the other there is a tendency 
to a distinct association of symptoms, fin,ally crystal- 
lizing into recurrent and eventually persistent syn- 
dromes, which may later become associated with 
definite lesions, not only in autonomic nerve structure, 
but in vessels, endocrme glands, viscera, joints and 
other tissues, and even the cerebrospinal nerve system. 

There is a recent tendency following Eppinger and 
Hess to refer them to increased tonus (not irritability) 
of either the parasympathetic or the sympathetic sys- 
tem, as vagotonic or sympathicotonic conditions. 
Nevertheless, Barker andSlayden in studying the re- 
actions in a series of nineteen cases found that the 
clinical manifestations were consistent with the phar- 
macodynamic responses in but seven. "In two ca.ses 
with increa.sed pilocarpine sensitiveness the clinical 
sympathicotonic and vagotonic signs were approxi- 
mately equal. The same was true for three epi- 

70 



nephrin sensitive cases. Clinically vagotonic signs 
predominated in five epinephrin sensitive cases." 

The term vagotonia is used by Eppinger and Hess 
to denote a "symptom-complex separated from a mass 
of nervous diseases hitherto grouped under the names 
of neurasthenia, hysteria, etc.," all of whose phe- 
nomena "may be identified with those of a state of 
stimulation of tlie extended vagus (autonomic nerve 
system)." 

It occurs, they say, in those of a "vagotonic dis- 
position," thus described: "Often familial in type, 
this condition is seen more often in young people of 
nervous tendency who are subject to cold hands and 
feet, which are frequently bluish and mottled. They 
have a tendency to swallow when talking, to flush 
readily, to sweat easily, the skin is moist, there is 
.slight internal strabismus, increased power of accom- 
modation, loss of sensation of touch in throat and 
larynx. The pulse is normally slow. Marked respira- 
tory fluctuations are present, due to irregularity in 
contraction of the diaphragm. Reflexes are increased, 
dermographism marked. The first complaint may 
be of gastric or intestinal disturbance." 

Vagotonics exhibit an increased sensitiveness to 
pilocarpine and other autonomic stimuli, and a 
relatively diminished sensitiveness to adrenalin and 
other sympathetic stimuli. 

Sympathicotonia is the opposite condition; sympa- 
thetic tone is heightened and there is a marked tend- 
ency to vascular spasm with a diminished sensitive- 
ness to pilocarpine and other autonomic stimuli, 
and an increased sensitiveness to the adrenalin group. 

The principal signs of heightened tonus in each sys- 
tem are exhibited in the following table. (Von 
Noorden, the younger.) 

Among the symptoms which may call attention to 
a heightened tonus in the cranial-sacral autonomic 
system may be mentioned the following: 

A. Symptoms in the domain of the mid-brain auto- 
iiomic: (1) Miosis, (2) accommodation spasm, (3) 
widened lid-slits, (4) von Graefe's sign. 

B. Symptoms in the domain of the hind-brain auto- 
nomic: (a) In the head: (1) salivation, (2) epiphora, 
(3) hot flushes with vasodilatation. (6) In the cardio- 
vascular system: (1) bradycardia, (2) slowed conduc- 
tion time, (3) pulsus irregularis respiratorius, (4) some 
forms of extrasystolic irregularity, (5) low blood pres- 
sure, (6) angina pectoris vasomotoria, (c) In the 
respiratory system: (1) bronchial asthma, (2) irregular 
tj-pes of respiration, (3) laryngeal crises, (rf) In the 
ciigestive tract: (1) inactive gag-reflex, (2) gastric 
hyperacidity, (3) gastric hypermotility and "gastric 
crises," (4) increased gastric tonus, (5) cardiospasm 
and pylorospasm, (6) "nervous" diarrhea, (7) "spastic" 
constipation, (8) mucous colitis. 

C. Symptoms in the domain of the sacral autonomic: 
(1) Spasm of anal sphincter, (2) spasm of M. detrusor 
of bladder with poUakiuria, (3) priapism. 

D. Certain other symptoms: (1) Eosinophilia, (2) 
tendency to sweating and especially to cold, clammy 
hands and feet, (3) lessened susceptibility to adrenalin- 
glycosuria, (4) oversensitiveness to pilocarpine, (5) 
certain forms of pigmentation, (6) reflex overexcita- 
bility of N. vagus (slowing of heart on nasal stimula- 
tion or on compressing the eyeballs) . 

In estimating the clinical value of Eppinger and 
Hess's classification one must recognize the distinction 
they make between tonus and excitability (irritability), 
the former indicating a constant state of tonic activity, 
the latter an increased readiness to respond under 
excitation. For instance, physostigmine increases 
vagus excitability (irritability) but does not itself excite 
the nerve, as does, for example, muscarine. Hence in 
the absence of other factors, physostigmine may not 
affect the cardiac action at all, but muscarine will 
arrest the heart unaided. These distinctions, however, 
will rarely apply in practice. 

S. Sohs Cohen has shown (1887) that it is not easy 



REFERENCE HANDBOOK OF THE MEDIC.\L SCIENCES 



Sympathetic N'erTons System 



to discriminate between heightened tone or irritability 
(erethism) of one system and lowered tonus or irri- 
tabiUty (apathism) of the other, since for example, 
paralysis of vasoconstrictors and excitation of vaso- 
dilators will produce the same phj'siologieal or clinical 
result. Moreover while certain individuals, having 
usually a family trait of undue mobility of the auto- 
nomic-sympathetic system, may exhibit chiefly vaso- 
constrictor (i.e. sympathicotonic) and others chiefly 
vasodilator {i.e. vagotonic) phenomena, yet, as a rule, 
the phenomena of autonomic-synipathetic disorder 
are mixed. Hence he proposed the name of i<aso- 
motor or autonomic ataxia, to indicate a want of 
taxis or coordination (imbalance), rather than an 
exclusive fault of either set of functions. He esti- 
mates that about one in twenty of the human race ex- 
hibit this imbalance, upon which basis such syndromes 
as hay fever, angioneurotic edema, urticaria, certain 
forms of asthma, vascular crises (pseudo-appendicitis, 
pseudo-hepatitis, pseudo-angina, pseudo-renal colic, 
etc.), various purpuras and hemorrhages, migraine, 
intermittent joint swellings, Graves' and Raynaud's 
syndromes, erv'thromelalgia, certain gastroenteric dis- 
orders, etc., as well as less well-defined symptom groups 
frequently mistaken for hysteria or neurasthenia, are 
built up under the incidence of various exciting 
causes and local determinants. 

The most frequent exciting causes are emotion, 
shock, fatigue, weather — especially temperature — 
changes, and toxic agents of internal or external origin. 
Trauma, eyestrain, and similar factors are the chief 
local determinants, direct and reflex. The endocrine 
system is usually involved in the complexus of phenom- 
ena, whether causatively or sequentially. Since 
the special symptoms may diff'er in various attacks 
— as asthma or croupous enteritis at one time, giant 
hives or epileptiform seizures at another — "the diag- 
nosis of the patient," i.e. his fundamental, and usually 
hereditary liability — the autonomic imbalance upon 
which the phenomena are superimposed — becomes 
all important. This diagnosis is made by both phys- 
ical and pharmacological tests. 

As a rule, the paroxysmal (critical) character of the 
vasomotor or autonomic disorders and the absence 
of distinctive signs of infectious malady or organic 
affection, will establish the probability of the diagnosis, 
either positively or by exclusion. It becomes more 
certain if the patient's family history and previous 
personal history show the occurrence of similar or 
related "spells," and certain physical characteristics 
and significant reactions to environment are present. 
They may not all be present at the same time, nor will 
any one patient show all of them at any one time; 
and but few of them are present continuouslv. 
Nevertheless, every case will show at some time a suffi- 
cient number of them to be significant. "They indi- 
cate persistent disturbance not only in the vasomotor 
nerves and centers, but in the autonomic system as 
a whole. Some of them arc the exact opposites of 
others." They may be summarized: 

Physical Characteristics. — Skin. — Marbling or 
mottling; dilatation of superficial vessels; petechise 
(purpuric spots) ; angiomata, telangiectases; pigmented 
spots; papillary excrescences; tattooed appearances, 
coming on especially on the naked body after exposure 
to cold; massive congestion of dependant parts, es- 
pecially hands, which may be pink, red, leaden blue, 
purple, or variously mottled. Fingertips often en- 
larged. Nails often curved, usually bicolored or tri- 
colored, dark at base, and exhibiting a dark red line 
at the tip; skin at base often thickened and brick 
red. Moist hot, or moist cold, hands. Excessive 
sweating, or less commonly scantiness of perspiration, 
even in svmimer; bromidrosis. 

Eyes. — Staring; widened commissure; retraction of 
upper or lower lid, constant or intermittent ; termulous- 
ness of lids on light closure; interrupted (jerky) 



descent of upper lid (hitch); v. Graafe's and v. Stell- 
wag's signs; paroxysmal winking; pigmentation in 
and around the lids. Rarely, droopiiig lids or squint- 
ing, narrowed commissure. Dilatation of pupil; 
inequality of pupils; intermittent dilatation; hippus; 
nystagmus. Distention and tortuosity of retinal 
vessels; spastic contraction of retinal vessels, rarely. 
Exophthalmos in pronounced disturbances. 

Thyroid Gland. — Moderately or slightly enlarged; 
soft. Enlargement intermittent. Rarelv atrophic. 

Heart and Vessels. — Easily disturbed. Palpitation. 
Blood pressure often very low (circa 90 to 100 systolic; 
60 to .50 diastolic). May be high in spastic paroxysms. 
Functional murmurs frequent; organic affections may 
be present incidentally or essentially. Vertigo is not 
uncommon. Tendency to various forms of hemor- 
rhage, usually slight. 

Nerves and Muscles. — Tremors and involuntary 
movements not uncommon; leg cramp occasional; 
niuscular throbbings common. Sudden jerkings of 
limb on awakening; sometimes epileptiform .seizures, 
principally nocturnal. Nightmare rather frequent. 

Blood. — Moderate anemia not uncommon. A 
marked tendency at times to autohemolysis. Hemo- 
globin and red cells not infrequently found in the 
urine when blood or blood pigment is not obvi- 
ous to the naked eye. Remarkable or persistent 
eosinophilia not uncommon. 

Chief Tests of Autonomic Ataxia. — Dermograph- 
ism either ischemic, hyperemic, or mixed. Factitious 
urticaria. Prompt local or general jnlomotor reflex. 
Blushing easily excited. Silver or silver-nickel leaves 
a bluish-black or brown mark when drawn over the 
face or the skin of the breast. (Exclude face powder.) 
Hot water intensifies redness of the exiremilies. Ice- 
cold water may change blueness to redness (cyanosis 
to hyperemia) in immersed member, the parallel non- 
immersed member being deeply cyanotic. Sometimes 
ice-cold water produces blackness of the nails. In 
dilative cases a cyanotic member (e.g. hand) if stroked 
or elevated, becomes pallid and when the stroking is 
stopped or it is again depressed, changes from white 
to pink, to red, to purple, to blue, as blood returns 
first to the capillaries, then to venules, and then to 
veins. In spastic cases the stroking or gravity has 
little effect. Humping of muscles is in many case^ 
easily produced. Fixation of eijes with command to 
open discloses latent retraction of upper lid. 



After this brief presentation of the principal facts 
concerning the disorders of the entire autonomic sys- 
tem, it but remains to say that the balance of the para- 
sympathetic and sympathetic systems is maintained 
by the coordinative tonic activity of all the nerve 
centers, proximal, peripheral, or central, regulating 
their normal action upon the autonomic tissues, and 
that failure at any point produces disorder, directly 
or by reflex. Failures may be constantly and con- 
sistently determined, or may be incon.stant and varied ; 
in the one case giving rise to more or less persistent 
and definite symptoms, in the other and more common 
event to a great variety of puzzling plienomena. 

Anaphylaxis. — The symptom-com))lox known as 
anaphylactic shock re-semblos closely the picture of a 
sudden and powerful excitation of the parasympa- 
thetic system. It is characterized by cardiac mhibi- 
tion, paresis of the abdominal vessels, lowered body 
temperature, spasm of the bronchial and visceral 
musculature, etc. Atropine, a vagoparalyzant and 
sympathetic stimulant, abolishes or antagonizes all of 
the phenomena. 

Ptomaine poisoning is in large part, depression or 
paralysis of the parasympathetic. Sympathetic and 
parasympathetic poisons are likewise produced by 
intestinal putrefaction, resulting from chronic obsti- 
pation. Enterotoxication (so-called autointoxication) 

71 



Hyiupallirllr Nitvous System 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



can, in view erf these facts, be the more easily under- 
stood. Leon Solis-Cohen. 



Pabtial and Recent Biblioghapby. 

Sherrington, C. J.: Sympathctio Nervous System; Encydi.p 
Bril.. Camb., 1911, vol. xivi., pp. 287-280. 

Langlcy, J. N.: Sympathetic Nervous System; Text Boole of 
Physiology (Schiifer), N. Y., 1900, vol. ii.. pp. 616-696. 

: The Autonomic System, Brain, 1903. 

Piersol, G.: Human Anatomy, Phila.. 1907, pp. 13.';3-1380. 

Gray's Anatomy (Spitzkal: Phila.. 1910, pp. 1066-1080. 

Onufrowici. B.: Sympathetic System, Rcf. Handbk. Med. Sci., 
1903, N. Y., vol. vii , pp. .573-.'i90. 

Brubaker, Albert P.: Text Book of Physiology, 1016, Phila., pp. 
C42-657. 

Meyer, H. and Gottlieb, R.: Experinientellc PharmakoIoEic ii., 
Aufl., Berlin u. Wien., 1911, p. 126. 

Cannon, W.: Bodily Changes in Pain, Fear, Hunger and Rage, 



N. Y. 



IVIS 



Med. Rev. 



d Allied Dis- 
p. 41. 



Biedl, A.: Innere .Sekretion, Wien, 1910. 

Sajous, C. E.: Internal Secretions and Principles of Medicine, 
Phila., 1903. 

Solis-Cohen, S.: Vasomotor Ataxia. I, Amer. Jour. Med. Sci., 
Feb , 1804; II, Trans. Assoc. Amer. Phys., 1902, vol. xvii., p. 6M 
et seq. 

: Visceral Angioncuroses, Trans. Assoc. Amer. Phys., 1900. 

vol. xxiv.. p. 527 ot seq.; also N. Y. Med. Journ., Feb. 19, Feb. 22, 
and March 5. 1910. 

: Notes on Vasomotor (Autonomic) Atax: 

Rev., 1912. 

: Graves's Syndrome, Raynaud's Syndrom 

orders, Internat. Clinics, 1909, series xix., vol. iii 

Eppinger, H. and Hess: Die Vagotonic; Eine klinische Studio. 
Samml. klin. Abhandl. Uber Pathol, u. Therap. der Stollwechs. u. 
Ernahr'st'n (von Noordcn). Berlin, 1910. 

Fox, E.: Influence of the Sympathetic on Disease, London. 
ISS.'i. 

Meryon, E.: On the functions of the Sympathetic System of 
Nerves as a Physiological Basis for a Rational System of Thcru- 
peutics. London. 1872. 

Barker and Slayden: On the Clinical Analysis of Some Disturb- 
ances of the Autonomic Nerve System with Comments on the So- 
called Vagotonic and Sympathicotonic States, Trans, .\ssoc. Amer. 
Physic, 1912, vol. xxvii. 

Cotton, H. A.: Disturbances of the Internal .Secretions in Regard 
to the Sympathetic Nervous System, Mod. Treat, of Nerv. and 
Mcnt. Dis., vol. i., pp. 469-517. 

Huber, Carl: Four Lectures on the Sympathetic Nervous System, 
Journ. Comp. Neurol., 1897, vol. vii , pp. 73-i. 

Timme, W.: Autonomic or Vegetative Nerve System, Journ. of 
Nerv. and Ment. Dis., December. 1914, pp. 745-754. 

Soltmannand Pilrher: Studicsonthe Vasomotor Center, Journ. 
of Pharm. and Expcr. Therap., 1914-1915, vols, vi and vii. 

Hoskins, U. and Ranson.S. W.: Vasomotor Reaction to Nicotine. 
Journ. of Pharm. and Exper. Therap.. 1915. p. 375. vol. vii. 

Schiifer. Sir Edward: An Introduction to the Study of the 
Endocrine Glands and Internal Secretions (Lane Medical Lec- 
tures. 1913). Leiand Stanford Junior University Publications. I'ni- 
versity .Series. 1914 



Symphorol. — l^ymplionil-sodium. Symphorol-lith- 
ium, aiul .Synipliorol-stroiitiuiii are the respective caf- 
feine siilplioiiate.s of these nietal.s. They are wliite, 
odorles.s. and bitter, are readily soluble in water, ex- 
cept the sodium salt, and are insoluble in ether, 
benzol, or chloroform. These salts are strongly diu- 
retic in dosage of gr. xv.-oi- (1.0-4.0) a day, and 
are claimed to retain the diuretic effect of the caffeine 
without its stimulating action on the heart and 
nervous system. The sodium salt is in common 
use under the simple term "symphorol." 

W. A. B.\STEDO. 

R. J. E. Scott. 



Symphyseotomy. — Definition. — .Symphyseotomy 
is an obstetrical operation devised to enlarge the bony 
pelvic ring by a division of the structures uniting the 
pubic bones in the symphyseal joint. 

Indications. — Its field of application is in cases of 
dystocia where the true conjugate is approximately 



between 6.5 and S.5 centimeters. The procedure may 
be done as an independent operation or as an accessory 
to high forceps, version, and breech extraction. 
.Mthough simple enough in itself the operation is 
rarely employed at the present time, because of the 
li;djili(y to injury of the maternal soft parts, and has 
been largely superseded by the advanced technique 
and the good results of abdomin.al cesarean section. 
Pubidtomy has also entered the field as a competitive 
procedure and is claimed to be attended with better 
general results. The shape of the pelvis is an impor- 
tant factor in deciding the field for application of 
symphyseotomy, including the male- or funnel-type 
pelves with ankylosis at the sacrococcygeal joint, 
justo-minor pelves with large fetal heads, or the pres- 
ence of other deformities. At the present time the 
operation may be regarded as of interest chiefly from 
the historical standpoint, although occasionally used 
by certain operators. 

The morbidity is necessarily high because of the 
postoperative complications, including hemorrhage 
with hematoma, abscess, fistula, lack of union between 
the pubic bones, cystitis, bladder injuries, bedsores, 
and general septicemia. A disturbance of the gait 
is not uncommon and the prolonged convalescence is 
a great disadvantage. In 1.36 cases of symphyse- 
otomy collected by Rubinrot the maternal mortality 
was about eleven per cent. Morisani collected 241 
cases done previous to 1894 and Xeugebauer collected 
278 cases with practically the same mortality rate. 
The infantile mortality varies from twelve to fourteen 
per cent., including all causes. 

Notwithstanding the condemnation of the opera- 
tion by most American authors, including Edgar, 
Williams, DeLee, and others, we find that a certain 
amount of favorable comment is occasionally pub- 
lished even at the present time. Thus Kehrer in an 
extended study of his cases from the Dresden " Frauen- 
klinik" compares a maternal mortality in 118 cases 
of symphyseotomy of 0.8 per cent, with 4.1 per cent, 
in 217 cases of pvibiotomy, the subcutaneous proced- 
ure of Frank being employed. Kehrer claims that 
if the technique proposed bj; Frank {Monalschr. f. 
Gehurlsh. u. Gyndk., vol. xxxiii. No. 6) is carefully 
followed the operation is simple and lacerations of the 
neighboring soft parts are avoided. Kehrer found it 
difficult, however, to avoid an injury to the corpus 
cavernosum of the clitoris, which resulted in hema- 
toma in sixty per cent, of his cases and in about thirty 
per cent, of these, thrombophlebitis of the lower ex- 
tremities followed. Subcutaneous symph_yseotomy is 
only recommended by him, however, for multipara;, 
the danger from lacerations in primiparae contrain- 
dicating the operation except where the soft parts 
are easily stretched. Version with breech extraction 
is the preferable method of delivery where the dis- 
proportion between head and pelvis is not great and 
efficient pains are present. In the presence of sepsis 
the operation should not be used, the extraperitoneal 
cesarean section or craniotomy in exceptional cases 
being indicated. Kehrer claims that the operative 
wound in symphyseotomy heals more readily than 
in pubiotomy. 

Technique. — Three types of symphyseotomy have 
been employed. The open or French method was 
developed by Pinard, in which the skin is incised over 
the entire symphyseal joint after which the recti are 
divided and the finger inserted into the prevesical 
space in order to protect the bladder. The symphysis 
is then opened from above downward and from before 
backward, followed by the division of the neighbor- 
ing ligaments. After" the expulsion of the child the 
bones are brought together with periosteal sutures 
and a special mechanical device is used to keep them 
in apposition. 

In the Italian method the upper margin of the pubic 
bone is exposed by a small transverse incision and a 



72 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



Syncope 



special form of knife passed behind the symphysis 
to the lower border. After the division of the joint 
spontaneous dehvery is awaited or forceps applied. 
The incision is then closed and a plaster-of-Paris 
dressing applied. 

In the subcutaneous method according to Ayres 
(Amer. Jour. Ohsl., July, 1897), the incision is made 
in the region of the subpubic arch and under the 
clitoris. With the finger in the vagina against the 
jiiisterior aspect of the joint a narrow knife is passed 
licliind the symphysis to the top of the joint and then 
carried downward until the latter is divided. In 
I'rank's similar procedure the joint is cut through a 
small incision over the middle of the same. 

George W. Kosmak. 



Syncope. — Syncope (Gr. a "cutting off") is usu- 
ally defined as a transitory condition, resulting from 
sudden lowering of blood pressure which in turn 
causes cerebral anemia and loss of consciousness. 
The patient seldom falls heavily, as sufficient warning 
is usually received. Those who are unfamiliar with 
the preliminary sensations often topple over, as in the 
case of robust medical students upon witnessing their 
first oper.ition. 

The English word "faint" of French origin has a 
much broader significance than syncope, because 
it indicates the weakened state which precedes the 
act, as well as the act itself. Etymologically, how- 
ever, the word does not mean weak, but is closely 
connected with "feign" and "feint," convejMng the 
idea of an imitation of death, a "sham death;" as 
Cowers says punningly, "a faint when feigned is a 
feint." 

The original Anglo Saxon word "swoon" is equi- 
valent to syncope, in that it denotes an act rather 
than a state. Its primary significance is obscure, for 
it also indicates deep sighing, referring, it is believed, 
to the sighing inspirations of one just before and 
during a swoon. 

However, the word syncope denotes something 
much more serious than a transitory loss of power 
and consciousness. The Greeks had a special word 
lipothymia, a "faint condition of the soul" to indicate 
the harmless swoon. Syncope, on the contrary, 
conveys in addition the idea of death occurring in a 
faint. Hence a distinction is made between "syn- 
cope" and "fatal syncope." By fatal syncope is not 
meant the old "death by the heart" or acute heart 
failure, which is one of the most common termina- 
tions of mortal illness, but a fatal swoon, occurring in 
a subject who may have been in apparent health at 
the time. Any condition which causes a harmless 
swoon seems able to cause sudden death in certain 
subjects; for example, puncture of the pleura or of an 
hydatid cyst of the liver. 

Modern literature is rather barren as to the subject 
of non-fatal syncope. Gowers {Lancet, 1907, vol. i., 
p. 565) discusses it quite fully, using the epileptic 
seizure as a comparison. The latter is attended by 
pallor, loss of consciousness, and a fall, symptoms 
which make up a simple swoon, yet in the epileptic 
seizure there is no lowering of blood pressure. The 
epileptic, however, is often subject to simple swooms, 
and these are regarded as epileptic equivalents. 
There appears to be no direct connection between 
cerebral anemia and loss of consciousness. Aside 
from the latter, however, the sudden lowering of blood 
pressure explains the phenomena of syncope satis- 
factorily. Nor is loss of consciousness present in- 
variably in fainting, and in abortive cases it is retained. 
Dimness of vision, showing the marked degree of 
cerebral anemia, may be present with retained con- 
sciousness; and subjects after a "near faint " may have 
dim vision for some moments. 

In general the more sudden the lowering of blood 
pressure, the more abrupt the swoon. However, 



a severe fall, which results in injury, is sufficiently 
rare. As a rule prodromes occur. The subject feels 
weak, sighs deeply, may experience nausea and dim- 
ness of vision. He had sufficient warning to lie down, 
whereupon the blood pressure begins slowly to rise, 
and the breathing to become deep and regiilar. 
The sensorium is quite clear, there is no difficulty in 
orientation and no retrograde amnesia. 

The mechanism of fainting is in part as follows: 
venesection up to a certain limit or severe hemorrhage 
of any origin may be regarded as the most tj-pical 
or demonstrable cause, since it affects all alike. In 
the days of universal phlebotomy the most robust 
patients were bled until they fainted from the effects 
of the falling bloodprossure on the cerebral circulation. 
The violent purgation resorted to in the days of heroic 
treatrnent produced the same result. Sudden tapping 
or aspiration of ascites and hydrothorax is a common 
cause of fainting. Aside from these typical cases, 
syncope is prone to affect the weakly and delicate, 
the convalescent, the fasting, and those actually ill, 
in whom it may be equivalent to a fatal termination, 
this being especially true of cardiac patients. The 
most acute tjT^e of syncope known is that which 
terminates the life in aortic regurgitation. Here the 
patient drops dead as if shot. It is so common in 
young women as to be almost physiological, and the 
most trivial causes of a p,sychic character are able to 
lower the blood pressure through the vasomotor 
center, as the sight of blood, certain odors, even 
certain sounds. Since crowded and overheated rooms 
are a most prolific cause of fainting, it is assumed 
that withdrawal of blood to the surface is the de- 
termining factor. 

The subject of syncope, both harmless and severe 
or fatal is thoroughly covered by Paulesco (Jour, de 
med. intern., Paris, 1900, iv., 810, 831). A harmless 
faint is characterized bj' the following symptoms: 1. 
Notable paUor of face. 2. Loss of consciousness. 3. 
Acceleration of pulse and slowing of respiration. 4. 
Disappearance of preceding symptoms when patient 
is placed on his back. 

If, however, a subject already ill, like a man with 
walking typhoid should swoon, the symptoms are 
more severe, approximating a state of collapse. They 
comprise: (1) Extreme pallor of face. (2) Skin covered 
with cold sweat. (3) Pulse hardly perceptible, 120- 
140. (4) Prolonged inspiration, involving all the 
inspiratory muscles. (5) Nausea. These patients 
when placed on the back with limbs elevated, recover 
very slowly, usually with the aid of caffein or cam- 
phor hypodermics. The pulse may remain weak and 
rapid for hours. Other symptoms seen at times are 
convulsive twitchings in tlie arms, a contracted state 
of the stomach and intestines, etc. .\ very sick man, 
upon rising from his bed may fall back in a syncope. 
Placed again in bed with head low, he is .seen to be 
deadly pale, with sighing respiration and frequent, 
almost imperceptible pulse. Colic and nau.sea may 
be present. These symptoms slowly disappear with 
recumbency. 

Cases like the following are occasionally seen — fatal 
syncope without sufficient apparent cause. A young 
girl with beginning typhoid went into a faint. She 
was merely slapped with a wet cloth. There was 
sudden stoppage of the heart and respiration. The 
tongue was drawn forward and artificial respiration 
practised without response. .\ needle in the heart 
provoked only a few contractions. The case after 
autopsy was "summed up as follows: initial pallor; 
pulse rapid, weak; respiration slow, deep and sighing; 
cold sweats, salivation, nausea, cramps in stomach, 
sense of hunger, vomiting, contraction of digestive 
tube; clonic convulsions; respiration arrested before 
cessation of heart beat; tonic convulsions; agonal 
respiration; cessation of heart -beat; evacuation of 
bladder and rectum. 

From animal experiments made in his laboratory 

73 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



Paulcsco concludes that fatal syncope must begin 
with pallor of tlie skin and visible mucosie; there are 
sensations of dizziness and ringing in the ears; the 
vision is obscured; the limbs flox and the whole body 
sinks. Consciousness niiiy or may not be lost, or the 
patient may fall asleep." -Vt the onset the pulse 
quickens, while respiration is slowed, becomes deeper, 
and interrupted with deep sighs. The face is covered 
with a cold sweat, the mouth fills with frothy .saliva. 
Nausea is present, with or without cramps in the 
stomach. There may be vomiting, colic, with bor- 
borygmi and desire f'or stool. The muscles of both 
trunk and extremities are the seat of involuntary con- 
tractions. As a rule tonic rigidity is present, while 
more rarelv doni are seen. Consciousness has become 
abolished, "respiration is now arrested, the heart beats 
two or three minutes longer, then ceases for tw-cnty to 
thirty seconds, and next continues to contract at long 
intervals, .\gonal respiration now appears, and there 
may be from three to twenty deep inspirations in which 
all the involuntary accessory muscles contract convul- 
sively. The patient yawns deeply, his face is con- 
torted, the terminal agonal inspirations show a falling 
off in violence, and respiration ce.ases altogether. The 
pulse now becomes rapid and feeble, soon ceasing alto- 
gether. Feces are frequently expelled, the urine less 
frequently. 

Section" shows the encephalon anemic, while the 
lungs, liver, and other viscera are congested. The 
state of the heart is characteristic. It is firm and 
contracted, the left ventricle empty 'with its cavity 
almost obliterated. The state of the right ventricle is 
similar, but less marked and it alwaj-s contains some 
blood. The auricles are distended and the heart has 
evidentl}' been arrested in sj-stolc. 

The jieculiar state of the heart appears to represent 
cadaveric rigidity of the myocardium, a viewb.ased on 
animal experiment. The stomach and intestines are 
in a state of spastic contraction. Their walls are 
firm, caliber considerably diminished. 

The rationale of syncope appears to be as follows: 
the facial pallor is due to contraction of the arterioles, 
which also extends to the brain causing the vertigo, 
dimness of vision, and loss of consciousness. In 
severe or prolonged cases the constriction reaches the 
vessels of the medulla, in which excitation of the vaso- 
motor centers may cause sweats, salivation, and con- 
traction of the digestive tube. The rationale of the 
terminal phenomena in fatal cases is not clear. Toxic 
affections predispose to fatal syncope because of the 
weakening of the vascular tonicity. When a subject 
has been in bed for a long period, the decubitus also 
causes loss of contractility, so that sudden sitting 
up causes faintness and fainting. This is very 
common in the first day of convalescence. Even in 
the normal subject protracted stanrling, even pro- 
tracted sitting, may cause the same symptoms. 

The heart failure in chloroform anesthesia is known 
as chloroform syncope. 

Paulcsco regards severe syncope from acute indi- 
gestion as a pure reflex, prolsably because it yields to 
morphine hypodermics. 

The treatment has already been indicated. The 

Eostural management aims lirst of all to cau.se the 
lood to return to the medulla, or to forestall anemia of 
the latter. If the patient can swallow, brandy will 
hasten recovery; if he cannot, ether and caffeine should 
be given by hypodermic. In suspended animation 
all the resources for that condition are invoked includ- 
ing heart massage. Edward Preble. 



Syndromes, Endocrinous. — The early mech- 
anistic conceptions concerning the push that lies be- 
hind the metabolism of the human body have slowly 
and gradually undergone modification untU the im- 
portance of a number of overlooked structures have 
forced themselves almost with a whirl upon the 



medical horizon. These structures are the endo- 
crinous glands. Their study now constitutes an 
enormous specialty. 

As early as 1828 Parry called attention to the 
relationship between enlarged thyroid and tachy- 
cardia, since which time the works of Johannes Miiller, 
Addison, GuU, Brown-Sequard, Marie, and many 
others have served as starting points for the building, 
up of a rich structure which is amply recorded in a 
score of monographs. The chief of these are Biedl, 
Internal Secretions (bibliography of 4,000 titles), 
1913; Falta, Ductless Cilands, 191.5; Parhon et 
Golstein, Les S(icr<itions Internes, 1909; Levy and 
Rothschild, Endocrinologie, 1913; Gley, les Sdcrd'tions 
Internes, 1914; Sajous, Internal Secretions, and the 
special articles in Lewandowsky's Handbuch der 
Neurologic, 1913. 

Out of this prodigious development, much of which 
is evanescent and hastily constructed, a large amount 
of solid substance remains and a number of permanent 
acquisitions have been made. The net result has 
been to show much more essentially than ever 
before the fundamental physicochemical foundations 
of biological metabolic processes as they are utilized 
in the upkeep of the anim.al machine. The view- 
point has been attained that a marked degree of 
chemical interrelationship takes place between the 
different organs of the body. That this is auto- 
matically regulated through the vegetative nervous 
system "(the old sympathetic) chiefly, apparently in 
some cases, though this is by no means clear, solely 
through chemical regulation. The disorders of this 
adjustment now constitute a special department of 
vegetative neurology, and are .nost conveniently 
grouped under the terms endocrinology, or the endo- 
crinopathies.' 

In the earlier period of the study of these cndo- 
crinopathies individual disease groups, uniglandular 
syndromes, were isolated. Among the most accentu- 
ated of these were Addison's disease, diabetes 
mellitus, mj-xedema, c'ertinism, and acromegaly, 
but of recent years it has been increasingly emphasized 
that whereas a certain group of symptoms, which may 
be linked to plus or minus activities of one or .another 
gland may be most prominent, nevertheless other 
glandular modifications are bound up in them and 
are not to be neglected. Hence has arisen the view- 
point that most of the endocrinopathies are, strictly 
speaking, poly- or pluriglandular syndromes. 

For many years, even back to the earliest days of 
primitive animistic magic, it has been held that every 
living tissue yields a cliemical product which will act 
upon other tissues. The early alchcmistic studies, 
those of Paracelsus, to the later work of Hahnemann, 
and the isotherapists, are all attempts to coordinate 
a host of empirically observed facts. They are all 
worth rereading if the reader wUl put himself in 
sympathy with them through a comprehension of 
the now strange symbols then used. 

Endocrinous glands for the present purposes are 
those structures which yield products termed hor- 
mones and chalones having some definite or specitie 
action related to, yet different from, enzyme activities. 
These structures are developed from different em- 
bryological formations. The hj-pophysis (posterior ■ 
lobe) and chromaffin tissues (suprarenal chiefly) 
are nervous; the thyroid and pituitary (anterior lobe) 
come from the buccal cavity; the pancreas and 
mucosa of the small intestine from the intestine, 
the parathyroids and thymus from the branchial 
arches (old gUl slits of fishes), the gonads (testes and 
ovary) and the interrenal bodies from the genital 
ridges. Some of these, in humans, merge into 
one structure, as thyroid and parathyroid, as chrom- 
affin and interrenal cells in the suprarenals, as 
hypophysis (posterior lobe) and pituitary (anterior 
lobe). The individual functions of each are ex- 
haustively treated in other sections of this Handbook. 



74 



REFERENCE HANDBOOK OF THE MEDIC.U, SCIENCES 



Srndromes, EndocrlnoDS 



The present article will attempt to sketch only the 
general outlines of the various uniglandular and 
pluriglandular syndromes. The more radical French 
scliool is followed, but at the same time attention 
should be called to the fact that the French school 
presentations contain gross fallacies, and should be 
niid cum grano salts. Still the clinical suggestions 
of these writers are so rich it is felt to be a better 
riiurse to call the attention of the physician to 
possible relationships rather than to take the more 
conservative attitude of directing attention only to 
that which can be indubitably proved. This whole 
-iibject is still so largely empirical that the principle 
'.f jnitting the h_\-potheses to a test will be found to be 
nil ire advantageous than that of believing only the 
nljvious. The former attitude may result in gaining 
ii^'ful therapeutic truths, the latter becomes monoto- 
nous and frequently encourages stupidity. 

Tlie more recent suggestive and extreme summaries 
(if Hiodl, Falta, Laignel Lavastine, Levi and Roths- 
rhild are therefore here summarized. 

UxiGLANDULAR Syndromes. — Thyroid. — Mjrxe- 

flema. — The chief symptoms are arrest of develop- 
ment, dwarfism, infantilism, infiltration of skin and 
imieous membranes, mental torpor, slow ideation, 
liifectivo memory, apathy, laziness, slowness, sleepi- 
n' <s, taciturn, awkwardness. The pulse is usually 
Muull, rapid and irregular, at times increased tension. 
There are constipation, diminished urination, hj^po- 
thermia and chilliness of the skin. Reflexes dimin- 
i>hed. The voice is frequently nasal, slow, monoto- 
nous and raucous. Headache is frequent and at 
times epileptic attacks occur. These are all symptoms 
ef diminished secretion. 

Exophthalmic Goiter. — A more or less complete 
eatalogue of findings for a lot of cases will include 
taehycardia, arrhythmia, anxiety, pulsations in the 
n ■ek, exophthalmos, epiphora, v. Graef's, Stellwag's, 
-Mr.bius' symptoms, facial paresis, cramps, tremors, 
n iiralgias, chiefly frontal and ocular, colic, hot 
flashes, profuse sweats, thermophobia, engorgement of 
the skin, dermographism, transitory edemas, pigmen- 
tation, urticaria, alopecia, diminution of electrical 
resistance, albuminuria, polyuria or glycosuria, 
anorexia, bulimia, vomiting, ptyalism, hyperchlor- 
hydria, diarrhea, dyspnea, amenorrhea, atrophy of 
mamma>, loss of flesh, agitation, emotional insta- 
bility, volubility, insomnia, anxiety, excessive anger 
or reverse, maniacal excitement, marked depression, 
cyclothymic variations, confusion, epileptic attacks. 
Eppinger and Hess- have endeavored to separate a 
vagotonic and sympathicotonic type. 

In the vagotonic type the more prominent signs are 
decreased lacrymation, less exophthalmos, with en- 
largement of the palpebral fissures, v. Graef's sign, 
abundant sweating, diarrhea, mild tachycardia, no 
alimentary glycosuria, pilocarpine and oculocardiac 
reflexes positive. In the sympathicotonic t_vpcs 
there are exophthalmos, dryness of eyes, violent tachy- 
cardia, glycosuria, oculocardiac reflex reversed or 
absent, increased reaction to adrenalin. Most cases 
are mixed in type. In all save infectious forms 
psychical influences are striking and ps3'chotherapy 
is extremely valuable in the early stages, less so in 
chnmic cases. Money worries bulk large in the 
etiology of the psychogenic cases. 

Thyroid insufficiencies, other than those of mjTce- 
dema are infantilism, obesity, Dercum's syndromes, 
psoudolipomata, alopecia, precocious loss of hair, 
scleroderma, urticaria, pruritus, recurring herpes, 
transitory edemas, migraine, asthma, constipation, 
raucous enterocolitis, acrocyanosis, Raynaud's syn- 
drome, localized erj-themas, rhinorrhea, glucose 
tolerance, genital instability, chilliness, mammary 
hypertrophy. 

Thyroid Instability (Levi and Rothschild). — From 
dyshypothyroidism: chilliness, baldness, headaches, 



depression, crj-ing, giddiness, pa.ssing edemas, neu- 
ralgic pains, suffocations, shivering, hot flushes, at 
menstrual period. With predominant dyshyperthy- 
roidism: thinness, increase of eyebrow development, 
hot flashes, palpitation, intestinal spasms, irritability, 
emotionalism, phobias, inquietudes, migraine, asthma, 
hyperidrosis. dysidrosis, tremors. Mixed cases: 
chilliness, shivering, migraine, frequent urination, 
neuralgic pains, distractable reddening of eyebrows, 
catamenia; neuralgias, anxiety, dilatation of palpebral 
fissures, swelling of feet, variations in volume of the 
feet, tremors, ner\-ous crises, hysterical attacks. 

Parathyroids. — Tetany. — This syndrome is unques- 
tionably related to parathvroid loss or deficient 
Parkinson's syndrome(?). The viewpoint of Lund- 
borg and of Gauthier is that this syndrome belongs 
here, and is a hyperfunction disorder, but it rests on 
very unstable foundations. 

Thyjnus. — Vagotonic Sjonptoms of Basedow Syn- 
drome(?): Profuse sweating, palpitation, lympho- 
cj-tosis, eosinophilia, sensation of weakness. 

Myasthenia of Erb-Goldflam(?): Headache, ptosis, 
external ophthalmoplegia, fixed or transitory palsies 
principally of the face, the neck, myasthenic electrical 
reaction. 

Thymus Loss : Idiocy of Klose and Vogt. 

TetanyC?): Basch. 

Suprarenals. — Addison's Syndrome and Suprarenal 
Insufficiency: Asthenia, arterial hypotension, morn- 
ing nausea and vomiting, lumbar pains, melano- 
derma, white lines on the skin, amyotrophy, aboulia, 
depression. At times myoclonus, "epileptic attacks, 
tetany, periodic palsies, delirium, mental confusion 
sudden death. 

Suprarenal-genital Syndrome: External feminine 
pseudo-hermaphroditism with virile .secondary sexual 
characters; suprarenal virilism; amenorrhea, gyneco- 
mastv, adiposis with easy bruising, all signs of 
feniinine maturity; hypertrophy of the clitoris, hyper- 
trichosis of masculine tj-]ie, masculine voice, muscular 
and nervous h3'i)erasthenia, active and violent 
sexual inversion; arterial hypertension, arterio- 
sclerosis; glycosuria. 

Sympathetic Paraganglia. — Chromaffine cells of the 
solar plexus, aortic paraganglion of Zuckerkandl, 
cardiac paraganglion of Wiesel and Wiesner, Luschka's 
carotid and coccygeal glands, tympanic paraganglia. 
The sj-ndromy of the affections of these glands is 
entirely obscure. 

Pancreas. — Diabetes Mellitus: Glycosuria, polyuria, 
polyphagia, polydipsia; neuralgias, pruritus, impo- 
tency, constipation, dry mouth, dry skin, diminished 
perspiration, atrophy of the testicles, abolition of the 
tendon reflexes, arterial hypertension, asthenia, head- 
ache, susceptibility to cold, perforating ulcer of the 
foot, syncopies, comatose or apoplectiform attacks, 
paralyses, vertigos, asthmatic dj'spneas, pseudo- 
angina, narcolepsy, depression, apathy, hypochondria 
and coma. 

Hypophysis. — Froehlich's Genital Adiposity Syn- 
drome: Adiposity, arrest of development or regression 
of the genital glands, of the genital organs and f hocorre- 
.sponding secondary sexual characters; somnolence. 

Syndrome of Hypophyseal Insufficiency of R<?non 
and Delille: Tachycardia, instability of the pulse, 
arterial hypotension, insomnia, anorexia, distressing 
sensation of heat, exaggeration of sweat secretion. 

-Vcromegaly : "A simple h\-pertrophy, not con- 
genital, of the upper and lower extremities and also 
cephalic," headache, amenorrhea, tendon reflexes 
increased, arrhj^hmia, syncope, perspiration, polyuria, 
glycosuria, sensitiveness to cold, neuralgias, acro- 
paresthesia, cramps, lancinating pains, lassitude, 
irritability, depression. 

Gigantism: ".Vcromegaly of the subjects in the 
epiphyseal cartilages wliich have not yet ossified," 
ini potency, amenorrhea, indolence, infantilism, aboulia, 
asthenia, "glycosuria, polyuria. 

76 



Syndroni€"i, KndcxTliiu 



RKFEREXCK HANDBOOK OF THE MEDICAL SCIENCES 



Diabetes liisipiclus(?) : Polyuria, polydipsia. 

Pineiit. — (ieuital Macrosomia: Abnormal increase 

in heiKlit, premature genital and sexual development 

with seiondarv sexual characters, hypertrichosis, 

exaggerated mental precocity. (SeePhieal Syidlrome.) 

Pineal Adiposity: DilTuse" obesity. 

Choroid Phxti.i. — Hydrocephalus: Hyperten.sion of 
the cerebrospinal fluid, rapid development, nervous 
and mental syndrome of ventricular hjijertension, 
obnubilation, idiocy. 

Omrivs. — Infantilism: Amenorrhea, absence of sec- 
ondary feminine characters, obesity, deficiency of 
hair, childishness. t> • i 

Acquired ovarian insufficiency: (a) Peripheral 
vasodilatation, subjective crises of heat, sweating, 
continuous or paroxysmal tachycardia, palpitations, 
arterial h>-pertension, insomnia, severe headache, 
facial neuralgia, lumbago, neuromuscular asthenia, 
memory instabilitv, irritability, enervation, hysterical 
crises; exaggeration of the sexual instinct(?), more 
often ab.scnt or inverted; obesity, restlessne.s.s, anxiety, 
phobias, impulsions, gastrospasm, constipation, vom- 
iting, vertigo, svncope. 

(6) "Vagotonic crises" before the menses and at 
the beginning of pregnancy, pallor, tendency to 
syncope, nausea, vomiting, constipation, diminished 
arterial tension, pulse rather slow, oculocardiac 
reflex positive, Samogyus's sign, psychic depression 
particularly connected with the development of the 
corpus luteum. These crises occurring before men- 
struation or at the beginning of pregnancy must not 
be confu-sed with the reactionary dyshyperthyroidism 
of the menopause marked by flashes of heat, sweat- 
ing, hypertension, paroxysmal tachycardia, pal- 
pitations, anxiety. 

"Hyperovaria" (Dalch(5): Precocious puberty, 
copious menstruation, pain before and during the 
first days of the period, intermenstrual leucorrhea, 
developed sexual instinct, well-marked eyebrows, 
thinness, pallor, small breasts, large pelvis, rounded 
lower limbs contrasted in size with the upper ones, 
arterial hypotension, craving for movement and 
action, enervation, tendency to loquacity, erotic 
crises. 

Testicles. — Infantilism: Defective development of 
the male genital organs, absence of secondary sexual 
characters, obesity, deficiency of hair, length of the 
lower limbs, small cranium, childishness. 

Acquired Testicular Insufficiency: Increase in 
height, diminution of the pilous system, glabrous state 
of the body, tendency to obesity, gynecomasty, 
frigidity, impotency, senility, arterial hypertension ( ?") , 
asthenia. 

The types of testicular insufficiency according to 
Rebattus and Gravier are: (a) The -sterile, (h) 
Eunuchoid gigantism, because the internal secretion 
of the testicle is established late. In this case there 
is a prolonged infantilism, (c) Eunuchism by cas- 
tration characterized by gigantism and infantile ap- 
pearance. The secondary sexual characters do not 
appear. (d) The reversive infantilism of Gandy. 
where simply a sort of asexual condition is noticed, 
with attenuation of secondary sexual characters and 
a certain degree of obesity, with late testicular diffi- 
culty in the adult. 

Dysh.vperdiastematia: Lower limbs short and cra- 
nium very large, pilous system well developed,especiaIly 
the mustache, thinness, persistence of youth, a degree 
of arterial hypertension, virile character, activity, moral 
and physical energy. 

Prostate. — Prostatic Insufficiency: Asthenia, diminu- 
tion of potency, neurasthenia, at times suicide. 

Hypertrophy of Prostate: Arterial hypertension, re- 
tardation of the heart, cerebral hemorrhages, genital 
excitation. 

PLtTRiGLANDDLAR Sn<DROMES. — Basedow's disease 
with thymic hypertrophy and vagotonic symptoms; 

76 



.sclerodermia and tetany, amenorrhea; Addison's 
syndrome; acromegaly, etc. 

Myxedematous with Thymic Hypertrophy: 
Tetany, acromegaly, Addison's syndrome, amenor- 
rhea, infantilism, mammary hypertrophy, etc. 

Acromegalic or ovarian insufficiencies with various 
disturbances, psychic, nervous, vasomotor, trophic, 
etc., connected at one time with the myxedematous, 
at another with the Basedowian series. 

Ovarian Predominance. — Thyroid Reaction to Ova- 
rian Insufficiency: Tachycardia, palpitations, perspira- ] 
tion, nervous irritability, vertigo, scanty urination, 
trembling, anxiety, etc. 

The difTcronces between these nervous manifesta- 
tions and the picture of the attenuated forms of exoph- 
thalmic goiter are very slight says Laignel-Lavastine. 
This i)athogenic conception permits of important 
therapeutic results one may ask, for example, whether 
the antibasedowian therapy with hcniatcithyroidin 
would not be of advantage in the nervous and jxsychic 
disturbances of the normal menopause which repeat 
one feature after another of the basedowian series. 

Dyshyperovaria of the Hypothyroid: Anticipation, 
prolongation and copiousness of the menses, menor- 
rhagia, metrorrhagia. 

"rhyro-ovarian Disturbances of the Same Signifi- 
cance. — Either ovarian insufficiency in the myxedema- 
tous series, or the dyshyperovarian in the basedowian 
series; in either case the nervous disturbances of the 
dysthyroid are modified by all the factors of the 
ovarian rhj-thm, whatever they may be. 

Hyiioplnjseal Predominance.- — Infantile giants, with 
their clinical varieties: feminism, eunuchism, cryptor- 
chidism, feminine pseudo-hermaphroditism, mental 
infantilism. 

Acromegalics with deficiency syndromes, myxe- 
dema, infantilism, amenorrhea, obesity, asthenia. 

Acromegalics with syndromes of hyperactivity, 
more or less vicious, synergetic or substitutive: simple 
or exophthalmic goiter, arterial hypertension and 
atheroma, lacteal secretion. 

Suprarenal Predominance. — Addisonian with amen- 
orrhea, impotence^ chilliness, tetany or, on the other 
hand, exophthalmic goiter. 

Very often basedowians, acromegalics, giants, with 
spontaneous glycosuria, alimentary or mereh' adrenal, 
the latter making it possible in certain cases to suppose 
a certain degree of suprarenal hyperactivity. 

Without Marked Predominance. — The case of 
Claude and Gougerot is an example: Loss of sexual 
characters, countenance old-looking, skin thickened, 
wrinkled, pigmented; chilliness, absence of per.spira- 
tion, asthenia, arterial hypotension, tetany; testicular, 
prostatic, suprarenal, thyroidal and perhaps para- 
thyroidal atrophy. " Smith Ely Jelliffe. 



References. 

1. .lelliffc and White: Diseases of the 
III. The Endocrinopathies. 

2. Eppinger and Hess; Vagotonii 
Monograph Series. No. 20, New York 



.System, Chap, 
and Mental Disease 



Synovitis. — This is defined as an inflammation of 
the synovial membrane. Two tissues bound a joint, 
namely, synovial membrane and cartUage. Opinions 
differ as to the possibility of an inflammatory process 
of the cartilage. The cartilage cells may proliferate, 
but otherwise the participation of the cartilage in any 
inflammatory process is largely a passive one. Hence 
the only tissue of a joint, strictly speaking, capable 
of inflammation is the synovial membrane. There- 
fore an arthritis is a synovitis and a synovitis is an 
arthritis. As a rule a myelitis in the region of a joint 
spreads to the synovial membrane, and becomes an 
arthritis as weU, and a synovitis (or arthritis) fre- 
quentl}' wUl involve the marrow of the bone end, but 
marrow involvement is not a necessary accompani- 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



Srpbllb 



ment of an arthritis; nor is an arthritis a necessary 
accoinpanimont of marrow involvement. 

For tiie etiology the reader is referred to the article 
on arthritis. The causation probably is always 
traumatic or infectious. The synovitis of gout is to 
be viewed as a traumatic arthritis caused by the de- 
position of uratic material in and about the joint. 
A sprain or "strain" of a joint causes a general syno- 
vitis which is most likely due to the irritating effect 
of the fluid poured out from the capsular rent. Loose 
bodies in the joint cavity may or may not cause a 
synovitis. They are as a rule well tolerated, unless, 
becoming pinched between the bone ends, they cause 
a sprain. Small sterUe foreign bodies inserted into 
rabbits' joints show a tendency to encapsulation, and 
cause little if any inflammatory reaction in the syno- 
\ lal membrane. Fluid in the joint is said to cause a 
.v\ iiovitis, by its mere presence. The synovitis, 
siiinetimes recurrent, accompanying a chronic (pus) 
myelitis at a distance from the joint is perhaps due 
to the "sympathetic" joint effusion. 

Pathology. — The normal synovial membrane is 
not a serous membrane like tlio pleura or the peri- 
toneum, with a mosaic of endothelial ceUs on its 
surface, but a connective-tissue membrane whose 
structure is peculiar, though differing somewhat in 
the various regions of a joint. Under an ordinary 
high power it is seen to consist of fibrous tissue with 
round or polyhedral cells at its surface, looking as if 
they had been dusted on with a pepper caster. These 
cells communicate by delicate processes with cells 
deeper in the membrane, but they have no stomata 
among them. Deep in the membrane are lymph 
spaces, but these lymph spaces do not communicate 
directly with the joint cavity. Attempts to inject 
them from the joint have been unsuccessful. 

In acute inflammations the changes produced in the 
synovial membrane are largely those produced in 
other soft tissues of the body, and the one circum- 
stance which distinguishes an inflammation in the 
synovia is that the exudate which results in poured 
out not only into the membrane, but also into the 
cavity which it lines, and the joint fills with the 
exudate, serous, fibrinous, or purulent, as the case 
may be. 

In chronic inflammations the synovial membrane 
becomes thickened and villous, and as a rule presents 
changes that enable us to classify its inflammations 
into two general types. In the first type the mem- 
brane is extremely cellular, and has much the appear- 
ance of lymphoid tissue. The thickened membrane 
consists largely of den.sely packed cells, though in the 
slow, dry forms the production of fibrous tissues may 
be abundant. In the second t,\-pe, while here and 
there collections of round cells may be seen, and while 
the superficial cellular layer may be slightly thickened, 
the membrane will consist mostly of loose-meshed 
fibrous tissue or of fat, or of both.' In these tissues 
dilated blood-vessels are quite abundant. 

The first type of synovitis is found generally with 
those diseases, such as tuberculosis, characterized 
by thinning and erosion of the cartilage, and by bone 
rarefaction; the second type, with the peculiar form 
of arthritis (known in this country as the hypertrophic 
form, in England as osteoarthritis, in Germany as 
arthritis deformans), characterized by bone and 
cartilage production. It is seen that the changes in 
Type I are practically the same as those in acute 
synovitis, ditTering simply in severity, destructiveness, 
and intensity. 

Results. — Acute sjmovitis and Type I of the 
chronic form may subside and leave the joint normal, 
or maj- end in fibrous ankylosis, depending on the 
cause and on the severity of the inflammation. 
Ordinary traumatic synovitis may subside entirely. 
In the case of sprains caused by loose bodies, recovery 
is the rule if the bodies be removed. Infectious 



synovitis may be followed by fibrous ankylosis or 
complete recovery. If the bone marrow be badly 
involved, the fibrous ankylosis may later change to 
bony, especially after a pus infection. Fibrous 
ankylosis is the rule after tuberculosis, complete 
recovery or fibrous ankylosis after gonorrhea. Type 
II causes distortions of the joint, but never adhesions 
between the bones. 

SiiiPTOMATOLOGv. — Pain, swelling, limitation of mo- 
tion are prominent in the first type (and of course 
in acute svnovitis). Fluid is usually present, and 
constitutional .symptoms are present or absent, ac- 
cording to the cause. A peculiar almost painless 
synovitis is occasionally seen in tertiary syphilis. As 
a rule, the synovitis of Type II is slower and not very 
painful. It is often "dry." 

Diagnosis. — To establish that a synovitis is present 
is usually easy from the disturbance of the function 
of the joint, from the pain, etc., but the cause of the 
trouble may be harder to elicit. It is to be borne 
in mind that the detection of the nature of a joint 
inflammation is made not by examination of the joint, 
but by an examination of the patient himself, and by 
a careful weighing of the history. For particulars 
along this line, as well as for the treatment, the reader 
is referred to the article on arthritis. 

Synorilis of tendon sheaths — tenosynovitis, tendo- 
vaginitis, thecitis, etc., presents little difference to 
inflammation of the joint synovia, except that it is 
uncomplicated by the presence of bone and cartilage. 

Tendovaginitis crepitans, so-called dry synovitis of 
the tendon sheaths, is most frequently seen over the 
long abductor and the short extensor of the thumb, 
and less frequently over the tendons of the toe ex- 
tensors. It follows as a rule overuse of these tendons, 
is somewhat painful, and is diagnosed by the peculiar 
rubbing feeling when the thumb is moved. Frisch 
(Archil' fiir klinische Chirurffir, 1909, Ixxxix., S23), 
maintains that the process is not a vaginitis but a 
peritendinitis. It yields readily to rest and pressure. 
Leonard W. Ely. 



Syntonin. — A term applied to the product 
formed when acid acts upon meat converting it to 
the stage of acid albuminate. F. P. U. 



Syphilis. — Synonyms: Pox; Lues; Lues venerea; 
Fr. V(^role; Ger. Lustseuche. 

Syphilis is a chronic contagious di.sease caused by 
the inoculation of the body by the Spirorhoeta pallida. 
It is met with throughout the world. There are two 
theories as to its origin: one' maintains that it was 
unknown in Europe previous to 1493. the other, which 
is generally accepted, is that it was brought to Si)ain 
by Columbus's sailors, as no description of syphilis 
can be found in European literature previous to 1495, 
and no bones have been found in Europe indicating 
syphilitic disease. In .America it was said to be very 
prevalent and among the Indians in Haiti it was re- 
garded as an ancient disease. It was also known to 
the .\ztecs, and skeletons with bone lesions have been 
discovered emphasizing its antiquity in tlie New; World. 

After the arrival of Columbus in Barcelona, in 1493, 
syphilis spread rapidly among the inhabitants of 
Spain. Its appearance in Europe attracted great at- 
tention and led to the first sy.<tenu\tic study of vene- 
real diseases and to tlie first attempt to differentiate 
between them. The years 149.3-1.")00 marked the 
introduction of syi>!ii!is"throughout Europe, Asia, .and 
the far east, following the voyages of discovery. In 
1495, Cliarles VII of France "began preiiarations for 
his campaign against Naples and gathered together 
an armv wliich included many mercenaries from sur- 
roundiiig countries, including'Spaniards afflicted with 
syphilis. Thus the progress of his army left a trail of 

77 



Syphilis 



UEFEKENX'E HANDBOOK OF THE MEDICAL SCIENCES 



sypliilis ill its wake. Starting among the French 
soltliors, it rapidly spread and was known as the 
morbus gallicus because of its supposed French origin. 

Against the theory of the American origin of syphilis 
is the undoubted fact that it existed in China and 
Japan in ancient times. It was known in China in 
the Chu dynasty in 1122 b. c. to 314 b. c. It spread 
from China to Japan. From Japan it spread to 
America, either by migration or by the drifting of 
junks on the ocean — more probably by migration 
from Uehring Strait and thence through the Great 
Salt Lake region into Mexico and South America. 

That sporadic syphilis existed in Europe in an- 
tiquity and even in modern times is probable, but 
never before had it assumed the character of a plague 
until the Siege of Naples. Its malignancy was no 
doubt the usual result of transplantation on a new soil, 
as is seen in other contagious and infectious diseases. 

John Hunter in 1707, in his endeavor to prove that 
gonorrhea and syphilis were identical, inoculated him- 
self with gonorrheal pus and produced syphilis, thus 
proving to his satisfaction the identity of the two dis- 
eases, and by the false conclusion drawn from one 
experiment, overturning the theories of the past 300 
years. 

Phillipe Ricord by hundreds of inoculations made 
in the years 1831 to 1837 finally proved that gonorrhea 
and syphilis were separate diseases. It was he also 
who distinguished between the hard and soft sore. 

Syphilis involves all classes and ranks of .society; no 
one is immune. Our knowledge of syphilis has in- 
creased wonderfully in the past ten years. Old theo- 
ries have been overturned and the treatment revolu- 
tionized. Three factors have cau.scd this: (1) The 
discovery of the Spirochwta pallida as the cause of 
syphilis. (2) The Wassermann reaction. (3) Ehr- 
lich's salvarsan. 

Diagnosis. — The Spirochirla pallida (Treponema pal- 
lidum) was discovered in May, 1905, by Schaudinn and 
Hoffman while working together in an effort to prove 
that the Ci/loryclcs litis of Siegal was the cause of syph- 
ilis. While examining specimens they noticed the 
frequent occurrence of a spirochete not heretofore 
described and which they could not find in uninfected 
people. The publication of their discovery soon was 
followed by confirmation by other observers. 

The Spirochnia pallidn is an extremely slender cylin- 
drical organism, from four to fourteen micra in length, 
having from three to twelve or more spirals or curves, 
which are very steep, forming acute angles. These 
curves are very regular and remain so whether the or- 
ganism is at rest or in motion. It takes a stain very 
poorly and is but .slightly refractive. The Spiroclia-taTe- 
fringcus with which Sp. pallida is most likely to be con- 
fused is much larger, the spirals are fewer and flatter, 
and it stains more deeply and is more refractive. 
The quickest and most satisfactory method of demon- 
strating the Spiroclia^la pallida in smears is by the 
use of India ink (Chin-chin Gunther; Wagner liquid 
pearl ink). 

The lesion to be examined is first thoroughly 
cleansed, preferably with green soap, and then well 
rinsed with water. Curettage is now made to draw 
serum, but not sufficient to produce blood. A drop 
of this serum is placed on a slide and mixed with a 
drop of the India ink mentioned above. The edge of 
a second slide is carefully drawn lengthwise over the 
smear so as to make a thin specimen. This dries in 
a minute or two when it may be immediately examined 
under a microscope using a condenser for dark field 
illumination. In this specimen the spirochetes and cell 
bodies appear unstained, while the rest of the field is 
black. Hiss and Zinsser in their Text-book of Bac- 
teriologj' describe a method of demonstrating the Sp. 
pallidn as follows: In the living state the organisms 
may be observed in the hanging drop or under a cover- 
slip rimmed with vaseline. It is extremely important, 

78 



in preparing such specimens from primary lesions or 
from lymph glands, to obtain the material from the 
deeper tissues, and thus as uncontaminated as possible 
by the secondary infecting agents present upon the 
surface of an ulcer, and also as free from blood as 
possible. The preparation is made upon a slide laid 
upon it .so that an even layer of oil, without air bub- 
bles, intervenes between the top of the dark chamber 
and the bottom of the slide. The preparation is then 
best examined with a high power dry lens. An arc 
light furnishes the most favorable illumination. In 
such preparations the iiighly refractive cell bodies 
stand out against the black background, and the 
motility of the organisms may be observed. The 
SpirocfuTla pallida is commonly stained by Giemsa's 
azur-eosin stain. This was the solution used by 
Schaudinn and Hoffman. The smears are fixed in 
methyl alcohol for ten to twenty minutes and dried. 
They are then covered with azur 1. solution. The 
eo.sin solution is then dropped on until an iridescent 
pellicle begins to form. Satisfactory specimens are 
obtained after ten to fifteen minutes of staining. 
Goldhorn's stain is more rapid and is applied to the 
smear for five minutes, first fixing in alcohol. 

Wassermann Reaction. — In 1901 Bordet and Gengou 
discovered the principle of complement fixation. 



^',:.r 



O" 



U"'- U 






0' 



Fig. 4719. — The Wassermann Reaction. ,4. The elements con- 
cerned in complement fixation; B, Wassermann positive: the com- 
plement is fixed in the first hemolytic system, and there is no 
laking of red blood cells; C, Wassermann negative; complement is 
free and joins the second hemolytic system causing laking of the 
red blood cells. 

Wassermann applied this to the determination in blood 
scrurn of the specific antibodies of syphilis and thus 
contributed one of the most valuable "aids to diagnosis. 
The reaction depends upon the fact that when an 
antigen, i.e. a substance capable of stimulating the 
formation of antibodies in man or animals, is mixed 
with its inactivated antiserum, in the presence of 
complement, the complement becomes fixed by the 
combined immune body and antigen so that it can 
no longer be found free in the mixture. Thus when 
red blood cells with inactivated hemol^-tic serum are 
added no hemolysis takes place, as there is no free 
complement. But if the mixture contains no anti- 
body the complement is left free and hemolysis occurs. 
The reaction may be gra|)hically represented as shown 
in Fig. 4719. (See the article on W assermann Reaction.) 

Noguchi introduced a modification of this technique 
that has been preferred by some workers. Still more 
recently following the cultivation of the spirochete, 
Noguchi made a serum, luetin, which he used for diag- 
nosis. This is dependent on an anaphylactic skin 
reaction as in the case of the von Pirquet reaction with 
tuberculin. 

Finally as an aid to diagnosis of bone lesions of 
syphiUs the i-ray has proved of incalculable value. 

Etiology. — Inoculation with the spirochete may be 



Reference Handbook 

OF THE 

Medical Sciences. 



PLATE LIX. 




Early papulo-Pustular and papular syphilitic eruption. 

(FrojH Ihe Collection of Photographs of Skin Diseases belonging lo Dr. John A. Fordyee. of .\'e-,e York ) 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



SypbUls 



direct or hereditary. For direct transmission an 
abrasion of the skin or mucous membrane, although 
e\er so slight, is necessary. The period of contagion is 
not a definite one. It exists through the active stages 
of the disease and therefore during the first one or 
two years. The pathological secretion from any 
lesion during the time of this activity is capable of 
producing syphilis. The patient's blood is also 
mfectious. A syphilitic child will transmit the dis- 
ease to a wet nurse but its mother may suckle the babe 
with impunity although she herself may show no signs 
of the disease. This is known as CoUes' law. The 
r< inverse of this. Prof eta's law, is also true, that a non- 
syi)hilitic child born of syphilitic parents is immune. 
This immunity is only apparent, for in both instances 
syphilis is already present. 

Course. — Before the real nature of the disease wa.s 
known, it was customary to divide syphilis into three 
stages: primary, secondary, and tertiary, and for 
(urivenience of description, this division has been 
retained. 

PrimaTtj Stage. — This extends from the appearance 
of the chancre to the appearance of the cutaneous 
eruption. By many writers a first stage of incubation 
is recognized, extending from the time of infection to 
appearance of the primary sore, usually three to four 
weeks. Taylor says that the extremes are ten to 
seventy days. The duration of the primary stage is 
about six weeks. Gilbert reports one case in which it 
was twelve days. The longest period observed is 
ninety days. It is often longer in poorly nourished 
subjects. There are no constitutional symptoms 
until toward the end of this stage when the patient 
usually feels somewhat indisposed. 

The primary sore (initial lesion, hard chancre, initial 
sclerosis, Hunterian chancre) of syphilis is the first 
evidence of syphilitic infection and occurs at the point 
of inoculation. Chancres may be genital or extra- 
genital. In the male the commonest location is on the 
glans, on the undersurface of the prepuce, or just 
behind the corona. Less often they occur on the 
scrotum, on the body of the penis, or over the sym- 
physis pubis. In the female they usually appear on 
the labia majora or minora, on the clitoris, or in the 
vagina. Innocent or accidental infections help to 
account for many of the extragenital chancres. They 
have been found on the lips, cheeks, chin, tongue, 
tonsil, fingers, thighs, abdomen, eyelid, breasts, and 
arms. 

A small papule or flattened plaque which shows no 
tendency to heal is generally the first sign of a chancre. 
This in a few days becomes indurated. In the major- 
ity of cases the induration is slight and is felt rather 
than seen. It is due to a dense round-cell infiltra- 
tion in the corium, especially about the blood-vessels. 
When picked up between the thumb and finger, the 
sore gives a firm rather clastic feeling as if a piece of 
cardboard were imbedded in the tissue. Occasion- 
ally chancres maj' reach a diameter of an inch and be 
definitely elevated. In fact a chancre is distinctly a 
new growth, differing in this respect from a chancroid 
which is primarily an ulcer. In about two weeks the 
neighboring chains of lymphatic glands become en- 
larged. This is followed by general glandular enlarge- 
ment, usually before the appearance of the eruption, 
but may be coincident with it. The glands are pain- 
less. The small papule or indurated spot mav remain 
as such and become slightly scaly, forming tlie dry 
scaling papule or patch. Again the epidermis over 
the papule may become eroded, forming the super- 
ficial erosion. The base of this erosion is dull red and 
is either nodular or spreads out into a thin round 
parchment-like induration in the corium. Only 
the center of the lesion is eroded and then a slight 
seropurulent exudation forms. The typical Hun- 
terian chancre differs from the above in that there is a 
distinct crater-like ulcer instead of an erosion. The 



ulcer is clean cut with sloping sides, its surface is 
smooth, and the exudation is seropurulent and scanty. 
A chancre not uncommonly may be complicated by a 
mixed infection of pus organisms or bv a chancroid. 
In this ca.se the chancroid develops in a' few days and 
follows its usual course. The chancre occurring in the 
regular tirne may be entirely masked by the preceding 
inflammation and the only evidence of its presence 
may be a persisting induration. 



JiFFERE.NTIAL DiAGNOSIB BF.TV, 

Chancre, 
."auso: Spirorhata paUidn. 
Indolent indurated neopla^'ni 

Xot autoinoculablp. 

Scanty seropurulent discharge. 

fsually single and does not 

tend to spread. 
I.ympb glands painless and 

discrete. 



EX Cbancke and Chancroid. 

Chancroid, 
"'ause: Bacillus of Durrpy. 
Rapid incubation (three to six 
days): spreading ulcer with 
perpendicular edges. 
Autoinoculable. 
Foul discharge. 
May have inflammatory are- 
ola about it. 
Lymph glands painful and 
mas.sed together: tend to 
suppurate. 



Secondary Stage. — The secondary stage or stage of 
eruption occurs from four to six weeks following the 
primary sore. The duration of this stage is from two 
to several months. It terminates with the disap- 
pearance of secondary symptoms and is not sharply 
defined. The outbreak is generally preceded and 
accompanied by a feeling of malaise, slight rise in 
temperature — 99° to 101°, rather marked anemia, 
frontal or occipital headache, some leucocytosis 
(10,000 to 15,000), and vague pains especially in the 
long bones and worse at night. The pain is occa- 
sionally localized to one part, which may be quite 
tender on palpation. Enlargement of the lymphatic 
glands is also constant, the glands nearest the point of 
infection being the first to enlarge. They are always 
firm, discrete, hard, painless, freely movable under the 
skin, and show no tendency to break down. The 
enlargement of the glands may persi.st for a long time 
following the di,sappearance of the secondary symp- 
toms. The inguinal, postcervical, and epitrochlear 
glands are always palpable whether other glands may 
be made out or not. The .skin and conjunctiva often 
have a yellowish tinge, evidencing liver involvement. 

At this period also there is some infection of the 
throat, especially of the fauces where it is sharply 
defined. There is also a marked redness of the soft 
palate, extending up and onto the hard palate, form- 
ing an arched slightly raised border. There may also 
bo moist papules or mucou.'s patches on all the mucous 
membranes and wherever there are folds of skin pro- 
ducing heat and moisture. These mucous patches are 
really papules whose tops have become excoriated 
by heat and moisture so that there is a slightly 
depressed ulcer covered with dirty, grayish membrane. 
They are usually painless and give slight discomfort. 
By this means they may often be differentiated from 
aphthous patches in the mouth, which they most 
closely resemble. 

The eruption is usually first noticed on the back and 
shoulders, spreading from there rapidly over the entire 
body including the face, head, and palms. It tends to 
follow the lines of cleavage. It is markedly polymor- 
pliic. Macules, papules, tubercles, and pustules may 
occur at the same time, although one form usually pre- 
dominates and gives the eruption its name. This 
polymorphism is in marked contrast with many other 
skin diseases, notably psoriasis and the lichens. 
Itching is not a common symptom, although there are 
exceptions to this rule, especially in the papular 
syphilides. It maj' or may not be followed by a late 
secondary erviption. The lesions of these so-called 
late secondary eruptions are usually few in number, 
located on one part of the body, and show marked 
asymmetry. They may take the form of tubercles, 
nodes, or "serpiginous plaques. The early secondary 

79 



Sypblllii 



UEFKRKNCE HANDBOOK OF THE MKDICAL SCIENCES 



symptoms iiiav also be accompanied by a more or less 
marked alopiria. The hair is distinctly thinned and 
falls out all over the scalp. Occasionally the t liininnK 
occurs in small patches, givinc it the so-called moth- 
eaten appearance. The patches are seldom entirely 
bald, but the hair that remains is dry and lusterless. 
Syphilitic alopecia is probably toxic and usually the 
hair returns promptly under syphilitic treatment. 

The noi7.s- may also show clKUiyes— they lose their 
shiny or plistening appearance, become dull, lusterless, 
corriigated in the transverse direction, and have a 
tendency to break at the free edge. Tlieir appear- 
ance, however, in no way differs from their ai)pcar- 
ance as seen in eczema and p.soriasis of the nails. 
Onychia and paronychia may occur during the course 
of the secondary stage. When they occur it is usually 
in cases in which the eruption has been profuse. 
Several fingers or toes may be involved. This condi- 
tion persists for months, yielding very slowly to 
treatment. 

Terlitiry Stage. — This is not a distinct stage. It 
does not refer to the time that has elapsed since infec- 
tion but to the character of the lesions. It is the 
stage of destructive lesions — of gummata and ulcers, 
and while rarely occurring under one year, its lesions 
are occasionally seen within a few months of infection. 
Usually these lesions occur after the signs of secondary 
syphilis have disappeared, but may occur with them. 

Syphilide.i. — The secondary eruptions of syphilis 
are the macular, papular, and pustular. 

The macular sijphilide (syphilitic roseola, erythem- 
atous syphilide) is usually the earliest eruption, occur- 
ring about the fifth to the seventh week, and 
occasionally even longer, after the occurrence of the 
primary lesion. It often passes unnoticed by the 
patient. The lesions are very abundant a.nd vary in 
size from a lentil to a dime. At first they disappear on 
pressure, perhaps leaving a yellow stain due to blood 
pigment. They are scarcely raised above the surface 
and the eruption suggests a mottling of the skin, and 
is often first seen on the back, especially if the skin is 
put on the stretch. The color varies from a pale pink 
to a dusky red, or perhaps to a raw ham color. It may 
be mistaken for medicinal rashes or one of the exan- 
themata, but is more chronic, and other symptoms 
of syphilis will be present to assist in its differentiation. 
The macular eruption may remain as such or may 
change into the papular or pustular type. This erup- 
tion usually appears quite suddenly, within a day, but 
does not attain its full development for a week or 
more. It remains for six or eight weeks and dis- 
appears gradually without scaling. Occasionally a 
temporary pigmentation may persist, and in untreated 
cases a limited macular eruption may recur during the 
first year but rarely after that. 

The papular syphilide, on account of the clinical 
differences in its eruptions, is generally described 
under the heads of miliary j)apular syphilide, flat 
papular syphilide, and tubercular syphilide. 

(«) The miliary papular syi)hilide (follicular syphil- 
ide, lichen syphiliticus) is not as common as the flat 
papular syphilide. It appears about the fourth 
month or may develop without a previous macular 
eruption. It is distinctly a follicular eruption involv- 
ing the hair follicles. The eruption comes out rapidly 
and is especially abundant on the face, arms, and 
trunk. The lesions are very numerous and tend to 
group or form segments, especially when the eruption 
occurs late. They vary from a pinhead in the small 
miliary type to one centimeter in diameter in the large 
miliary syphiloderm. The color is first a faint red, 
changing to a dull red or raw ham color and having a 
violaceous tinge, and in the larger lesions there is a 
slight tendency to umbilication. The surface of the 
skin is distinctly rough to the touch. Usu.ally the 
lesions are conical and are rarely capped by a "small 
vesicle or vcsicopustule. They are chronic, lasting 

80 



weeks and gradually fade away leaving a few fine 
scales. The miliarjr syphilide does not usually yield 
to treatment as easily as other forms. Occasionally 
the patient complains of slight itching. It must 
be differentiated from lichen planus which it fre- 
quently resembles. Lichen planus is very itchy, is 
seldom" general but often limited to arrns and legs, 
is slower in developing, and is more chronic. Kerato- 
sis pilaris is rare on the body but more common on the 
arms and legs, is very chronic, and other symptoms 
of syphilis are lacking. 

(6) In the fiat papular syphilide (discoid, lenticular 
syphilide) , the papules are flattened, not niuch elevated, 
and are somewhat oval. They vary in size from a pin- 
head (small flat papular syphilide) to that of a quarter 
(large flat papular syphilide) and are usually discrete. 
They are scattered over the entire body and are most 
abundant about the mouth, genitocrural region, and 
on the forehead below the hair line (corona veneris). 
This form of eruption is the mo.st common one. It 
follows the macular eruption in most cases but may 
bo the only one to appear. It comes out long after 
the appearance of the primary sore. The lesions 
develop rapidly and continue to appear for several 
weeks. Relapses on limited areas are not uncommon. 

Occasionally an annular or circinate syphiloderm is 
ob-served, especially in the negro, and usually about 
the face and neck. It seems to develop from the per- 
ipheral extension of a small papule, the center of which 
sinks or is absorbed, or from a larger papule, the 
center of which is imperfectly formed or has become 
sunken or flattened. 

The tubercular syphilide (nodular syphilide) devel- 
opes from the papule. Definite nodes or tubercles 
may occur, the size ranging from a pea to a walnut or 
larger, the color varying from a bright to a dusky red. 
They are usually late lesions, rarely occurring in the 
first year, and from the so-called late secondary 
lesions. They may undergo resolution with sear 
formation, or may ulcerate. These lesions are very 
apt to be located on the face or to be grouped in certain 
regions and form circles or segments of circles, produc- 
ing the reniform or horseshoe-shaped lesions (serpig- 
inous syphilide). From the confluence of these 
tubercles much enlargement and deformity result, 
especially about the face and ears. 

The ulcerative tubercular syphilide is usually a, 
very late manifestation, and occurs chiefly in neglected 
cases or in cachectic subjects. It is a tertiary lesion. 
In this variety, the tubercular patch, instead of under- 
going absorption or scar formation, softens in spots 
and ulcerates, producing a purulent discharge which 
dries up forming greenish-black crusts. The ulcer has 
the typical clean-cut wall and serpiginous outline of 
syphilis. In most cases these forms are mixed, the 
central portion of the patch being atrophic, and the 
border having a tendency to break down into srnall 
ulcers. This type simulates lupus vulgaris, which, 
however, is of very slow growth, occurs in early life, 
is very asymmetrical, and leaves more di.sfiguring 
scars. Epithelioma has a pearl}' rolled-over border 
and scanty secretion. 

Vesicular Syphilide. — The existence of this form is 
denied by many. When it does occur, it is usually the 
beginning of the pustular type and is associated with 
pustular lesions. 

Bullous Syphilide. — This is araretj-pe in acquired 
syphilis, but common in the congenital form. When 
it occurs, it is also associated with pustular syphilide. 

The gummatous syphilide (gumma) is a late lesion. 
When it occurs early a malignant type of syphilis is 
usually indicated. A gumma usually .starts as a small 
firm mass subcutaneously, and may project slightly 
above the level of the skin. It grows slowly or rap- 
idly, taking from ten days to several months to reach 
a size varying from that of a pigeon's egg to that of 8 
hen's egg. At first it is seldom painful. As it in- 
creases in size it may be quite painful and tender, and 



Reference Handbook 

OF THE 

Medical Sciences. 



PLATE LX. 




ERYTHEMATOUS SYPHILIDE OF PALM OF HAND. 

(From Ihe Collection of Fholographs of Skin Diseases belonging lo Dr. John A. Fordyce. of Sew York.) 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



SypbUU 



as the skin over it becomes stretched, the normal color 
changes to a pinkish then to a dusky red, and the lesion 
softens and tends to ulcerate, although it may undergo 
absorption even when quite large. Usually the skin 
becomes adherent over it and breaks down at one or 
more points, producing a small or large ulcer having a 
punched-out appearance and with a yellowish-green 
discharge and an offensive odor. The arms and legs are 
the most frequent sites of gummata. Without treat- 
ment, the ulcers usually jjersist and increase in size, 
while the gumma extends into the surrounding tissue. 
Occasionally gumma extends to the deeper parts and, 
especially about the face, may involve the bones. 
Gumma must be differentiated from a non-syphilitic 
abscess or tumor and this may be very difficult. A 
history of the case, other evidences of syphilis, and 
several Wasscrmann blood tests may be necessary 
before a diagnosis can be made. A sx-philitic ulcer 
mu.st be differentiated from an epithelioma, a varicose, 
or a tuberculous ulcer. An epithelioma has a pearly 
rolled-over, waxy or indurated edge. The ulcer has a 
tendency to bleed easily and its secretion is scanty. 
It also grows slowly. 

Tuberculous ulcer develops usually before the age 
of pubert}-, runs an extremely slow course and often 
with other signs of tuberculosis. The ulcers are 
comparatively superficial, with irregular undermined 
edges and .slight discharge. They leave yellowish, 
hard soars and are refractory to treatment. 

A varicose ulcer is complicated by enlarged veins. 
It is usually single with thick, swollen, edematous 
edges. It has a sloping floor with profuse granulations 
that bleed freely. 

Palmar and plantar syphilides show certain charac- 
teristics due to the thickened epidermis and to the irri- 
tation and pressure to which it is subjected in these 
regions. They may appear with the secondary erup- 
tion. Patients with a macular eruption usually show 
some mottling of the palms, the erythematous lesions 
being covered with finescales. In the papular erup- 
tion, dusky red, slightly elevated papules, pea size or 
smaller, are common. Occasionally they appear as 
hard, grayish-white masses imbedded in the skin, and 
having a scaly fringe around the border of the papule; 
the edge of the fringe is directed centrally. Untreated 
they may undergo partial absorption, become flat- 
tened and coalesce to form irregular patches with a 
few papules around them. The patches are slightly 
scaly both in the center and at the periphery, and 
may be fissured. This partial scaling or epidermal 
fringe is due to the efforts of the epithelium to cover 
the patch. Psoriasis has lesions in other localities or at 
least a history of them and the lesions are more eleva- 
ted. Squamous eczema may be limited to the palms, 
but usually extends onto the fingers and is often itchy. 

The pustular tiiiphilidc (miliary pustular syphilide, 
acneform syphilide, large and small flat pustular 
syphilide) may originate as such or may develop from 
the macular or papular forms. In size and character 
the lesions do not differ from the previously described 
papular lesions. This eruption is usually seen in per- 
sons of low vitality or in tho.se poorly treated, it 
usually occurs during tlie first six months or it may 
occur as a relapse later in the disease. Erosion.s, 
ulcerations, crust formations, and cicatrices arc 
common complications. 

Heredit.\rt or Congenital Syphilis. — This may 
be transmitted from either father or mother to the 
offspring. The syphilitic eruption may be present at 
birth but, if the child lives, more commonly develops 
during the first few weeks after birth. There are 
various forms of this eruption. 

_ The macular erupt ion c(msists of finger-nail to palm- 
sized, indistinct, yellowish, brownish red or copper- 
colored patches, covered with a shining and wrinkled 
epidermis. The palms, soles, buttocks, thighs, and 
genitals are frequently affected. 

Vol. VIII.— 6 



The papular eruption often develops from the mac- 
ular and with it forms the commonest svphilidc in the 
hereditary disease. The papules resemble the mac- 
ules in color and surface luster. They are prone 
to form condylomata when moist. The bullous 
form is comparatively common. The.se flat or semi- 
globular bulla' most frequently occurring on the soles. 
palms, and face are evidence of severe infection, 
When ruptured an ulcerated base is exposed. Vesicu- 
lar and pustular eruptions are rare. The tubercular 
and gummatous syphilides are not common and when 
present appear some years after birth. 

Coryza, rhagadcs or fissures about the mouth, and 
bossy swellings of the frontal bones are frequent 
lesions of congenital syphilis. 

The teeth also commonly bear evidence of the dis- 
ease. The upper central incisors of the permanent 
.set are the ones affected. They are peg-shaped, the 
incisor edge being notched and narrower, and are 
known as Hutchinson teeth. 

General Lesions. — S>-philis is a disease which 
affects not only the skin but the whole system and may 
cause le.sions in all the organs of the" body. These 
lesions will be but briefly mentioned in this section 
because they are treated "more fully in other parts of 
this H.\XDBOoK. Sj-philis of the skin is the most fre- 
quent, syphilis of the mucous membranes the most 
infectious, syphilis of the nervous system the most 
malignant manifestation of the disease (Keyes). 

The nervous system may be affected in many ways 
giving rise to varied symptoms. The early signs are 
pains, intellectual and moral upset, impairment of 
general health and of the sexual power. Later more 
advanced lesions may cause paralyses, ocular or facial 
paralyses, hemiplegias, deafness; or epilepsy, insanity, 
tabes dorsalis, general paresis, etc. 

Lesions of the eije due to syphilis are iritis, chorio- 
retinitis, optic atrophy, and interstitial keratitis. 

The skeletal system has certain lesions due to 
syphilis. They are periostitis, osteomyelitis and 
gumma formation. The commonest site for the latter 
is the tibia. Gumma may also localize in the joints 
forming an osteoarthritis which often results in 
marked deformity. The disease may cause arthralgia 
or hydrarthrosis and may involve the bursa;. 

The teeth are affected as described under Hereditary 
ByphiVis. 

The hair, as already mentioned, tends to fall out in 
the secondary stage. 

The muscles are rarely and the tendons hardly ever 
affected. The lesions that may occur are contracture, 
myositis, and gumma. 

Involvement of the lungs has been recognized clin- 
ically, more often in recent years because of the x-ray. 
Interstitial pneumonia occurs almost exclusively in 
hereditary syphilis. Sclerosis, bronchiectasis, and 
gumma are the forms assumed by acquired lesions. 

The liver may be affected in both hereditary and 
acquired disease. In the former there is a diffuse 
hepatitis. In the secondary stage of the acquired 
type there may be a jaundice but the liver shows no 
lesion. Gummata with resulting scars are common in 
the tertiary phase. 

The Digestive Tract. — The esophagus, stomach, and 
intestines are rarely involved, though they may occa- 
sionally be the site of gummata, ulcerations, or stric- 
tures. The rectum is the part of this tract most com- 
monly affected. 

The Circulatory System. — Endocarditis has been 
reported in association with gummata. Fibroid 
induration and amyloid degeneration are probably 
results of the obliterating endarteritis of the coronary 
vessels. Syphilis plays a very important rcMe in 
arteriosclerosis and aneurysm. Xodular gummata 
developing in the adventitia of arteries, with or 
without involvement of the intinia, are distinctive of 
syphilis. 

81 



Svphllls 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



Kidneys. — Acute syphilitic nephritis may prove 
fatal in the secondary stage. The kidney shows no 
distinctive lesion but resembles that in any acute 
infectious disease. Occasionally gummata are found 
in the kidneys. 

Syphilis occurs in the testes in two forms — gummat- 
(lusgrowths and interstitial orchitis. 

Prognosis. — .\ child born with active manifesta- 
tions will die in a few days to a few weeks. In cases 
where the signs appear in the first six months the 
mortality is very high. 

With "regard" to the benign course of acquired 
syphilis, the prognosis is good in most well-treated 
cases. In a certain percentage of cases serious after- 
consequences residt. No assurance can be given in 
any one case that these will not occur. In the so- 
called parasyphilitic stages, tabes and general paresis, 
the prognosis is poor. These generally become pro- 
gre.ssively worse. The prognosis of syphilis of the 
blood-vessels is also poor. Gummata, on the otlier 
hand, are very amendable to treatment provided this 
is begun before destruction of the organ occurs. 

Syphilis does not necessarily always shorten life. 
The duration of life naturally depends on the location 
of the lesions. Frequently, however, in the malignant 
form, four to ten years arc the toll. 

Treatment. — This should be begun the in.stant the 
diagnosis is made and should be pushed to the limit 
of tolerance. The diagnosis in the primary stage is 
made by means of the dark field illuminator, provided 
no mercury has been used on the lesion as mercury will 
generally cau.se the disappearance of the Spirochcela 
■pallida. After the .second week of the primary, a 
VVassermann blood test is positive in fifty per cent, of 
the cases and the percentage increases rapidly to 
nearly 100 per cent, at the beginning of the secondary 
stage. If neither of these methods is available 
and a diagnosis cannot otherwise be made, the 
appearance of the .secondary eruption should be 
awaited. No constitutional treatment should be 
given until the diagnosis is definitely made, as other- 
wise the secondaries may never develop, and the blond 
tests may be negative for some time and an element 
of grave doubt will occur to both the patient and the 
physician whether a mistake was made. The patient 
also will be less inclined to continue treatment. 
Microscopical examinations of doubtful lesions ought 
never to be neglected as the finding of the treponema 
(spirochete) will enable treatment to be started im- 
mediately, which will no doubt cut short the disease 
as shown by the absence of clinical signs and negative 
laboratory tests. \ j)atient should never be pro- 
nounced cured until rei)eated blood tests in the ab- 
sence of clinical signs, a provocative salvarsan injection, 
and a lumbar puncture have all given negative results. 

A thirty-three per cent, calomel ointment thor- 
oughly rubbed into the skin immediately after an 
exposure is generally prophylactic. Metchnikoff and 
Roux claim that it is preventive if used within eight- 
een hours after infection. It is quite certain, how- 
ever, that if carefully used within four hours after 
exposure the development of a primary sore is rare. 
Wide excision and cauterization about the point of 
infection may po.ssibly prevent the development of 
the disease. Excision or cauterization of the begin- 
ning chancre is useless as the disease has by that time 
already become sj'stcmic. 

The treatment of syphilis has been revolutionized 
in the past ten years, and especially so since the dis- 
covery of the Wassermann reaction and Ehrlich's 
salvarsan. Mercury and salvarsan or ncosalvarsan 
are the constant drugs u.sed in the treatment of 
syphilis. Iodides have no curative action and their 
use is usually limited to old ca.ses where ulcerations and 
gurnmata are present. They are occasionally used in 
the intervals between mercurial treatments. Mercury 
is given by the mouth, by intramuscular injection or 

82 



inunctions. Fumigation is rarely used, thougli it is 
said to be serviceable in ulcerative lesions. One-half 
dram of calomel is vaporized in a receptacle and the 
patient's body is placed in a cabinet in which the 
mercury is vaporized. Mouth treatment formerly 
extensively used, is being rapidly displaced by intra- 
muscular treatment. When t;iblets are given it is 
usually in the form of the protoiodide of mercury or 
the bichloride of mercury, from 0.0032 to 0.005.5 gram 
(sV to T>j grain) three or four times a day. Either of 
these may cause some irritation of the stomach and 
perhaps slight cramps or diarrhea. Gray powder 
(hydrargyrum cum creta) is also used internally 
especially in infants and children, as it is less likely 
to cause gastrointestinal irritation. The dose is 
from 0.020 gram (§ grain) three times a day. Calomel 
(0.30 to 0.12 gramor^ to 2 grains three times a day) is 
rarely used at the present time. Blue mass 0.20 to 
0.40 gram (3 to 6 grains) a day, is another form of mer- 
cury now seldom used. It is very apt to cause stomati- 
tis without warning. Mouth treatment should not be 
continued indefinitely even when not contraimlicated 
by some intestinal symptoms or soreness of the gums 
and teeth, because a tolerance is in time established 
and the treatment becomes inefi'ectual. 

The intramuscular method is the most satisfactory 
way of giving mercury, as it insures accuracy of dosage 
and does not interfere with digestion. The disad- 
vantages are the occasional pain and induration which 
may occur. Of the soluble salts of mercury, the 
bichloride and biniodide are most commonly used. 
These are given daily or every other day for about 
two months, depending upon the tolerance of the 
patient, or until slight salivation ensues. The bi- 
chloride of mercury is more irritating than the bin- 
iodide, but either salt may cause some pain. The 
former is usually mixed in water so that 60 c.c. (ten 
minims) equals 0.003 gram (5';f grain). Thedosebeing 
60 c.c. to 120 c.c. (ten to twenty minims). The pro- 
toiodide is also mixed in water. Sterile albolene may 
be used as a vehicle but it is harder to prepare and 
has no advantage over water. Other soluble salts 
of mercury may be used, as the benzoate, cacody- 
late, or peptonate. 

During the mercurial treatment the patient is 
instructed to use a soft tooth brush and powder fre- 
quently to keep the teeth as clean as possible. He is 
also given an alkaline antiseptic mouth wash, one of 
the cheapest and best being a saturated solution of the 
chlorate of potassium in water, about 3.25 grams (fifty 
grains) to 30 c.c. (one ounce); one per cent, phenol may 
be added to this if the patient complains of much 
sorene.ss in the mouth. The use of tobacco is pro- 
hibited. Any mucous patches should be touched with 
ten per cent, solution of nitrate of silver. 

Treatment by rubbing into the skin the unguentum 
hydrargyri (fifty per cent.) is a well-recognized form. 
The usual method is to rub in vigorously 2 grams 
( J dram) of the ointment for six successive nights, 
using a separate surface of the body each night. On 
the seventh night a warm bath is to be taken and the 
next night the patient begins again with the inunc- 
tions on the surface first selected. The patient is 
told to rub the ointment in till the hand remains free 
from grease. 

Salvarsan and Neosalvarsan. — Various compounds 
of arsenic have been advocated from time to time in 
the treatment of syphilis but after a trial they gener- 
ally have been discarded in favor of mercury. Mer- 
cury has been the only stand-by in the treatment of 
syphilis for centuries and still is quite generally used 
in conjunction with salvarsan in successful treatment. 

The organic preparation of ar.senic known as atoxyl 
(the sodium salt of para-amidophenylarsenic acid) 
w.as introduced by Thomas, of tlie Liverpool School 
of Tropical Medicine for the treatment of trypano- 
somiasis, but did not produce the results expected; 
however, it led to a further study of allied combina^ 






Reference Handbook 

OF THE 

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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



SyphUlH 



tions of arsenic and finally to the discovery of salvar- 
san by Ehrlich, aided by Berthein and Hata, in 1910. 

In 1905 Schaudinn discovered the cause of syphilis 
to be a spirochete and he stated that this organism is 
closely related to the trypanosomes. On this account 
Uhlenhuth emplo}'ed atoxyl with success in the treat- 
ment of experimental spirillosis in fowls. Later 
Uhlenhuth, Neisser, and Metchnikoff successfully 
employed it in sj-philitic infection in animals. It was 
later used in the human subject with some success 
but its employment in man soon showed it to be 
extremely dangerous, nephritis, optic atrophy, and 
severe gastric disturbances resulting, so that it has 
fallen into disuse. 

Ehrlich by producing substances closely allied to 
atoxyl and testing their effects as to toxicity on animals 
found that salvarsan, popularly known as 606 (the 
diary number of Ehrlich's series of arsenic compounds) 
was the least toxic to the organs of the body and most 
toxic to the parasites. Salvarsan is the dihydrochlor- 
ide of dioxydiaminoarsenobenzol (Ci2Hi202X2.'Vs2- 
HCI2) ; it contains thirty-four per cent, of arsenic. The 
peculiar molecular formation of 606 is .said to prevent 
the arsenic from combining with the tissues and thus 
prevents arsenical poisoning. 606 is a specific for 
spirilla. It is a yellow powder, readily oxidized into 
poisonous substances and must be kept in vacuum 
tubes. It is soluble in water and physiological saline 
solution and it is strongly acid in reaction. The 
acidity is neutralized by caustic soda solution. 

Neosalvarsan, introduced later, is the dioxydi- 
aminoarsenobenzenemonomethane sulphonate of sod- 
ium (Cr.HiiOjAsjNjCHjO). It has the advantage of 
ready solubility; the after-effects are less severe and 
for intramuscular use it is less irritating. It does not 
seem, however, to produce such permanent results. 

The successful treatment must overcome the anat- 
omical location of the spirochetes and depends in large 
part on the time since infection took place. In some 
cases it seems that the spirochete and the tissues of 
the body become tolerant of each other and salvarsan 
has little effect compared to its action in the earlier 
stages. The parasites of syjjhilis are found chiefly in 
the connective tissues and are seldom found in the 
blood. In the chancre they are extremely numerous 
in the dense base and in the connective tissue of the 
blood-vessels. The infection spreads along the lymph 
spaces and the parasites locate in the vessel and nerve 
walls and in isolated groups. The secondary symptoms 
are due to the previous spread of the parasite through- 
out the body. 

Salvarsan is far superior to mercury in causing the 
rapid disappearance of sj-philitic symptoms. One 
dose of this drug being equivalent to prolonged mer- 
curial treatment. Salvarsan also acts promptly in 
those resistant cases in which mercury has been used 
for some time with little effect. In other words, the 
spirochetes become resistant to the prolonged use of 
either mercury or arsenic and a change from one to 
the other is often followed by marked benefit. For 
this reason it seems advisable to change from time to 
time the medicament employed. 

During the European war, which is stiU in progress, 
it has been impossible to obtain a supply of salvarsan ; 
to meet the need thus created various substitutes have 
been devised. The most closely allied in its thera- 
peutic effects is that produced imder the direction of 
Dr. J. F. Schamberg of the Dermatologieal Research 
Laboratories of the Philadelphia Polyclinic, known as 
arsenobenzol. It is claimed to be identical in all its 
essential properties with salvarsan, and clinical 
experience tends to corroborate this statement. 

Diarsonol is a Canadian substitute for salvarsan 
and was tested in the laboratories of the University 
of Toronto before being placed on the market. 

Both the above preparations are less easily dissolved 
than the German product, although it is claimed they 
are identical with it and are equally effective. Occa- 



sionally rather severe reactions follow the use of 
diarsenol. Such reactions seem to be lacking in 
arsenobenzol. 

The contraindications to the use of salvarsan are 
niyocarditis, extensive nephritis (not syphilitic), 
diabetes, and ulcer of the stomach are usual contra- 
indications. Organic heart disease and aneury.sni 
are not contraindications but it is inadvisable to give 
larger doses than 0.:J or 0.4 gram especially for the 
first dose. Diseases of the central nervous system, 
optio- atrophy and iritis are not contraindications. 

Salvarsan is now given without untowarri effects 
in man)- diseases in which it was formerly consifiered 
dangerous. The complications and fatalities formerly 
attending the administration of the drug are now geri- 
erally believed to have been due to faulty technique 
or to the weakened condition of the patient. 

After-effects. — The occasional after-effects of sal- 
varsan and neosalvarsan are severe headaches, nausea. 
vomiting, chills, and fever. The temperature may nm 
up to 103 to lO-t". The untoward .symptoms usually 
last but a short time. Arsenic completely disappears 
from the body in three or four daj's, when salvarsan 
is administered intravenously and in about ten days 
when it is given intramuscularly. 

Preparation of Patient. — The evening previous to 
an intravenous injection of salvarsan the patient 
should be given a cathartic. A light breakfast only 
should be eaten on the day of the injection. After 
the drug has been given, the patient should remain 
quiet for the rest of the daj'. No food should be 
eaten until all probability of nausea has pa.ssed. It 
is also advisable to take a cathartic that same evening. 
The urine should be examined in all cases previous to 
the administration of salvarsan. Evidence of kidney 
irritations should lead one to observe extreme caution 
and to use a small dose. 

Methods of Administering Salvarsan. — In the 
early days of salvarsan, many methods were proposed, 
at present, however, practically the only method in 
general use, is the intravenous injection. Occasion- 
ally the intramuscular method is used. Suspensions 
of salvarsan in olive oil or liquid paraffin have been 
injected both intramuscularly and subcutaneously. 
This method seems to be le.ss irritating. However, a 
number of cases of necrosis of the tissues have fol- 
lowed its use and it seems to possess no material 
advantage over the ordinary intravenous injection 
with saline solution. The ordinary dose of salvarsan 
is 0.4 gram; larger doses, while used, seem- to possess 
no advantage over a moderate dose. The first dose 
given is usually 0..3 or 0.4 gram, succeeding doses may 
be larger, never exceeding O.G gram. 

For intravenous inject ion the method of preparation 
is as follows: The salvarsan is poured into a sterile 
graduate of 1.50 c.c. or 200 c.c. capacity and sterile 
water is added so that 0.1 gram of salvarsan is repre- 
sented by 20 c.c. of fluid. Larger dilutions seem 
unnecessary, although when first brought into use 
the dilution was made so that oO c.c. of fluid repre- 
sented 0.1 gram of salvarsan, and a dose of O.G salvar- 
san was equivalent to 300 c.c. of solution. This 
increased the time of administration without possess- 
ing any advantage. Stronger dilutions than 0.1 pram 
to 20 c.c. have no material benefit except a very slight 
shortening of the time of administration and they 
occasionallv seem to produce more violent reactions. 

The solution having been made up as indicated, the 
graduate is thoroughly shaken until every particle of 
salvarsan is dissolved and the solution is absolutely 
clear. \ fifteen per cent, solution of caustic soda is 
added drop bv drop when a precipitate forms: the 
graduate is frequently shaken and when the solution is 
neutralized the precipitate is again dissolved. An 
additional drop of NaOH is usually added to prevent 
the precipitate reforming when the solution cools. 

Neosalvarsan has the advantage of being easily 
prepared. It is readily soluble in sterile water, which 

83 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



must be cool. The dose is fifty per cent, larger than 
that of salvarsan, but the amount of solution need not 
be increased. Neosalvarsan must be used soon after 
mixing or decomposition may occur with the forma- 
tion of poisonous compounds. 

It is quite essential that freshly prepared sterile 
water be used in making this solution; freshly pre- 
pared saline .solution is first injected into the vein and 
if this runs frcclv without swelling or infiltration of the 
ti.ssues, the salvarsan may be run in. The patient 
should experience little or no pain at this time, much 
pain usuallv indicates infiltration of the tissues about 
the vein bv salvarsan. If this is apparent it is bettor 
to shut off the salvarsan and flush the vein out 
thoroughly with .saline solution, then withdraw the 
needle and insert at another point. 

After having injected the salvarsan it is advi.sable 
to allow a little saline solution to flow in, in order to 
flush the vein thoroughly. For intramuscular injec- 
tion neosalvarsan is preferable to salvarsan as it 
causes less pain. The preferable site for injection is 
the buttocks. The powder is dissolved in from 12 to 
18 c.c. of sterile water or salt solution, 2 c.c. of a one- 
half per cent, .solution of novocainc is first injected, 
using a needle about five centimeters in length. With- 
out removing the needle, remove the syringe and fill 
it with the neosalvarsan solution and then slowly 
inject, then remove the needle quickly and mass.age 
the part. Hot applications are usually indicated, 
occasionally an opiate is necessary. The pain or 
discomfort may last for one or two weeks. 

General constitutional treatment must not be lost 
sight of during the active stages of syphilis. The 
anemia, nervousness, general malaise, cachexia, and 
worry should be noted and treated as usual. A patient 
is apt to become so worried by the length of treatment 
and fear of complications that he may find a new com- 
plaint daily. Excessive smoking and alcoholism 
should be prohibited. 

The treatment of hcreditaTy syphilis is essentially 
that of the acquired disease in .adults with the neces- 
sary changes in dosage and method. 

frcnlmenl nf Primary Stage. — .\ftcr the full devel- 
opment of the lesion, local treatmoiil, beyond clean- 
line.ss and a dusting powder, is unnecessary, for it 
accomplishes nothing. Excision or cauterization, 
unless done at the very onset of the syphilitic process, 
does not cut short the disease nor lessen its severity. 
The treatment in this stage consists of giving maxi- 
mum doses of salvarsan or neosalvarsan once a week 
for from three to six or more doses, followed by the 
intramuscular injections of mercury in the form of 
either the soluble or the insoluble salts. These 
mercurial injections arc preferably given in the but- 
tock using a one and one-half inch needle. If a solu- 
ble salt is used, the treatment will be continued daily 
or every other day for about two months, when an 
intermission of four to six weeks should be given, fol- 
lowed by another course of salvarsan and mercury. 
If an insoluble salt is used, an injection of the salicyl- 
ate or gray oil should be given weekly, for five or six 
doses of the latter or ten to fifteen of the former, 
each dose representing 0.005 to 0.120 gram (one to 
two grains) of mercury. .\t the end of each course 
a rest is taken and the treatment repeated for a sec- 
ond course of a like nature. .\t the end of six months 
a blood test may be made. If it is positive, the treat- 
ment should be repeated; if negative, it is advisable 
to continue treatment for at least a year, but many 
prefer to give no treatment for another period of three 
months when a second Wassermann test should be 
made. If it is still negative, a provocative injection 
of salvarsan is advocated. If, after this, the blood 
test is still negative, all treatment may be discon- 
tinued, though a test made every six months for a year 
or two is advisable. 

Secondary Stage. — The treatment in the secondary 
stage also consists of the use of salvarsan and mercury, 

84 



but it is preferable to give two or more injections of 
mercury previous to giving salvarsan, as untoward 
reactions arc less likely to occur and the therapeutic 
effect is greater. Mercury should be given in the 
same manner as in the primary stage, but it is advis- 
able to start salvarsan injections with a smaller dose, 
say 0.3 or 0.4 gram. Succeeding doses may be made 
larger if thought advisable, although a dose of 0.4 or 
O..'? gram seems to accomplish as much as a dose of 
O.G gram. The local treatment of the eruption is 
not very important, but the use of a mercurial oint- 
ment to the skin will tend to h!v.sten its absorption, and 
is therefore desirable. In the severe papular and pus- 
tular forms baths of bichloride two to eight grams 
(one-half to four drams) in 120 liters (thirty gallons) 
of water for five to fifteen minutes may be used. 

Tertiary Stage. — The treatment of the tertiary stage 
of sj-philis dilTers little or not at all from the treatment 
of the other two stages except that possibly iodide of 
pota.ssium may be given in this stage, although some 
occasionally use it in the secondary stage. It is 
seldom necessary to give the iodide in doses exceeding 
0.6.5 gram (ten grains) three times a day. It may be 
given until the tertiarj- lesions have been healed. 
However, under the use of salvarsan these lesions dis- 
appear much sooner than under the iodides. 

A fourth state or parasvTDhilis was formerly con- 
sidered. It is now known, however, that so-called 
parasyphilitic affections are simply active syphilis 
occurring in the nervous system. 

William Thomas Corlett. 
WiLLiA-M Craw Gill. 



Syringomyelia. — It is impossible to give a satis- 
factory definition of a disease with such protean symp- 
tomatology and diversity of pathological findings. 
In general the name is given to a process of new 
growth in the gray substance, or to intramedullary 
cavities of varied origin, marked clinically by disturb- 
ances of motor, sensory, and trophic nature; by 
frequent bulbar symptoms, by almost constant reflex 
changes; usually by extreme chronicity. Reports of 
cavity formation in the spinal cord date back to a 
description of fitienne in 1.564. Morgagni and San- 
torini recounted a case in 1740. Numbers of descrip- 
tions date from the early part of the last century. 
Calmcil in 1828 pointed out the influence of develop- 
mental anomalies. OUivier first used the terra 
"syringomyelia," though his conception of the cavity 
formation needed later correction. A little later it 
was recognized that the pathological condition syringo- 
myelia not infrec)uently was associated, clinically, 
with muscle atrophies (Landau, Nonat, LenhossSk 
Gull). This a.ssociafion did not escape the acumen 
of Duchenne de Boulogne: "I found in a good part 
of my cases that electrocutaneous as well as ordinary 
cutaneous sensibility was affected. This anesthesia 
is often so marked that the patient does not feel the 
strongest current or the ferrum candens." 

Up to the publications of Kahler and Schultze in 
1882 few clinical facts had been collected, but anatom- 
ical views had become sifted and well formulated. 
Five chief views maintained that the cavities resulted 
from: (1) a dilated central canal (Stilling, Waldeyer); 
(2) retrogressive changes in foci of chronic myelitis 
(Hallopeau, Charcot, Joffroy); (.3) molecular degen- 
eration due to vascular changes (Lockhart Clarke); 
(4) destructive metamorphosis of tumor masses 
(Grimm, Simon, Schultze); (5) certain developmental 
anomalies (Virchow, Leyden). In 1882 simultaneous 
publications of Kahler and Schultze quickened clinical 
interest and formulated rules of diagnosis. Since 
then the literature has become immense; the mag- 
nificent monograph of Schlesinger in 1901 represents 
the sum of our knowledge of the disease and has 
been freely drawn upon in the preparation of this 
article. 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



SyrlnKomyella 



Pathological .^-atomt. — The cord may be hard to 
remove on account of marked kyphoscohosis. There 
may be pachymeningitis, or pia or nerve-root thicken- 
ing. The cord may seem flat and thin, the medulla 
small; or it may appear swollen in certain regions, 
especially in the neighborhood of the cervical enlarge- 
ment; on section there may be cavities varying greatly 
in shape, vertical extent, and diameter. Frequently 
there are no macroscopical cavities, but irregular 
reddish-gray tumors in the gray substance. The 
medulla oblongata is often involved in the tumor or 
the cavity-formation. The process may be limited 
to one side or to a small part of the cord ; or it may ex- 
tend throughout the cord and medulla oblongata. 
Usually the formation of tumors or of cavities involves 
the gray substance about the central canal. The 
anterior commissure is most often intact. One or 
both posterior horns may be attacked, or the ventral 
portion of the posterior columns; if the destruction ad- 
vances, a large part of the gray matter disappears and 
the whole of the posterior and a large portion of the 
lateral columns become involved. The cavity walls 
may be smooth or ragged, may be lined by ependyma 
or closed by a proliferation of the glia. There may be 
evidence of old hemorrhage. As a rule, all changes 
are most marked in the cervical cord. 

Microscopically, the tumor masses consist of glia 
cells and fibrils. The cavities are lined by a firm mem- 
brane that at times shows an epithelial covering. 
The tumors spring from the central part of the cord, 
the posterior horns, the posterior commissure, etc., 
and spread through the gray substance toward the 
posterior columns along the posterior median septum. 
The ultimate cause of the growth is to be sought for in 
certain developmental anomalies of the central can.il 
or of the glia. The central canal may be undidy large 
or markedly irregular with diverticula. It may fail 
properly to develop and be marked by persistence of 
the dorsal process which is a characteristic at a certain 
stage of fetal growth; or this diverticulum may be cut 
off and may persist as a dorsal canal seemingly inde- 
pendent of the central canal (Leyden). At other 
times nests of embryonic glia cells (ependj'ma) lie 
scattered in the neighborhood of the central canal or 
along the dorsal line of closure about the posterior 
median septum; and these may spontaneously, or 
under influence of some irritation (trauma), begin to 
proliferate and give rise to the glia tumors or gliosis 
(Hoffman). The cavity formation may depend on 
many different processes — on dilatation or diverticula 
of the central canal, softening after trauma, hemor- 
rhage, or inflammation, destruction of tumor masses, 
retrogressive changes in glia prolifer.ations (the com- 
mon syringomyelia). But cavities and cysts after 
hemorrhage, myelitis, disintegration due to trauma, 
are rarely to be reckoned with the changes known as 
syringomyelia ; they are stationarv and not progressive. 
Another element is necessary, viz., some congenital 
disposition of the cord — an inherent tendency of the 
ependyma or glia cells to proliferate. Developmental 
anomalies of the whole central nervous system or only 
of the central canal and its neighborhood are found, 
therefore, in most cases of syringomyelia; anomalies of 
vessels and of the vascular connective tissues are also 
common and contribute to further proliferation and 
later cavity formation. 

Next to the posterior horns and posterior commis- 
sure the anterior horns and the posterior columns are 
the parts of the cord most affected. The cells of the 
anterior horns are either directly invaded by the 
gliosis, or are destroyed by hemorrhage, or at times they 
undergo atrophy at a distance from the process — per- 
haps as a result of inherent weakness. The ventral 
portion of the po.sterior columns — the ventral field of 
the posterior columns; the dorsomedial sacral bundle 
of Obersteiner; Schultze's comma tract — most fre- 
quently suffers. The p^Tamidal tracts may either be 
directly invaded or they may undergo degeneration 



from pressure of the growth at a higher level of the 
cord. 

Bulbar Lesions. — Pathological changes occur in the 
median line or laterally, especially along the entering 
vagus roots. The cavities are a.s a rule small — mere 
slits rather than holes. Those lying near the median 
line are due to developmental "anomalies, while the 
Lateral rifts and cavities have their origin in vascular 
changes, in inflammatory processes. The cavities are 
lined with glia, but usually there is no distinct evidence 
of proliferation. The vessels are enlarged and pres- 
ent in unusual number. The central cavity when 
present is lined with ependyma. The lateral lesions 
may involve the nerves from the twelfth to the fifth; 
the twelfth, tenth, ninth, and descending roots of the 
fifth are most often implicated. The process ends 
at the pons. The fillet is frequently destroyed. The 
process is nearly always predominantly imilateral. 

In judging of pathological findings one must remem- 
ber the possibility of various artefacts. Tears may 
occur along the po.sterior horn and commi.ssuro and in 
the gray substance from pressure and crushing during 
removal of the cord (Kolisko). Cavities may result 
from putrefactive gas-form.ation, and changes may go 
on in the specimen while it remains in the hardening 
fluid if this is not frequently changed during the first 
days. Van Gieson has called attention to the various 
artefacts in an exhaustive article. 

Etiology. — Not infrequently the disease seems to 
have direct relation with trauma of some sort. Ac- 
cording to Minor a central hematomyelia due to 
trauma is often the starting-point of the abnormal 
process. Perhaps hemorrhages due to trauma during 
birth act in the same way (Schulfze). It is plausible 
to think that, in the case of the developmental anoma- 
lies described above, the incitement to glia prolifera- 
tion may be given by trauma; experimental evidence 
favors such a view (Schmaus). The theory has been 
advanced that even peripheral trauma or a panaritium, 
etc., may, with the predisposition already mentioned, 
and through the agency of an ascending neuritis, be 
able to .start the process of proliferation; this supposi- 
tion has little probability. Different infections, es- 
pecially typhoid and influenza, may act like trauma in 
certain cases and supply the initial irritation leading to 
later tumor-growth. Excessive temperature changes, 
particularly exposure to cold, .seem occasionally to act 
in the same way. Syiihilis may lead to cavity-forma- 
tion through vascular and meningeal lesions, but has 
little influence in the production of the progressive 
changes which characterize syringomyelia. I>>prosy 
plays no role as a causal factor. The relations of 
trauma to the disease are most important from a. 
medicolegal standpoint. Most often the trauma is 
an accident in the already developed disease. Rarely, 
in congenitally predisposed subjects, it may be the 
primal cause of the process. Not infrequently it leads 
to decided exacerbation of the quiescent disea.se. 
Most often its effects are disastrous, due to peculiari- 
ties of the disease and not to severity of the trauma 
(trophic joints, spontaneous fractures, etcl. 

Symptomatology. — From the character of the patho- 
logical lesions it is plain that symptoms must be pro- 
tean and capable of almo.st endless combination. In 
the most usual localization of the process in the cervi- 
cal enlargement the picture is fairly typical. Light- 
ning pains in one or both arms, or paresthesia-, espe- 
cially sensations of burning or coldness, or "burnmg 
cold," not infrequently precede striking changes. 
.\trophy of hand or arm muscles is a marked feature; 
it may" be unilateral. The small hand muscles are 
mo.st often involved; the process may becin in the 
shoulder group. Usually when atrophy is well marked, 
sensory changes can be demonstrated. These at first 
are found over small areas of the hands, arms, or 
shoulders, and there may be only a moderate di- 
minution of temperature perception, not a complete 

85 



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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



loss. Viisoinotor disturbances and trophic chaiiKcs 
of varied kind may be noted in the skin, subcutaneous 
tissues, bones, and joints. The knee-jerks are in- 
creased; if the process involves one arm predominantly 
the knee-jerk on the same side will be the livelier. Later 
on. contractures may occur; the atrophy progresses; 
unilateral bulbar symptoms may develop; spastic 
paraplegia becomes marked; further trophic changes 
are seen; sensory changes cover wide areas and in- 
crease in intensity; the sphincters may be affected. 

If the cavity-formation involves the dorsal and 
lumbar cord, pain and paresthcsiie will be felt in 
corresponding nerve roots. The muscle-atrophy will 
affect the adductors, (luadriceps extensor, peroneus 
group, the back extensors, perhaps the glutei and 
other muscles of the calves. The knee and Achilles 
reflexes are usually increased. Sensory and trophic 
disturbances are found in the lower extremities or in 
the trunk. The sphincters are frequently affected. 

When the lumbosacral cord is involved there is 
atrojjhy of the glutei, knee flexors, or foot muscles^ 
often unilateral. Sensory changes are demonstrated 
in the feet, perineum, bladder. The sphincters are 
usually affected early, but they may escape. Trophic 
changes are often peculiar. The leg and foot may re- 
main small or may be unduly large; bone and joint 
changes, panaritium, malum perforans. are frequent. 
The patellar as well as the Achilles jerks are usually 
increased; a weighty sign is loss of the .Vchilles reflexes 
with normal knee-jerk. 

Association with congenital hydrocephalus or spinal 
deformities, spina bifida, is common. 

Scnsnry Disturbances. — The principal sensory 
changes were well described in the first publications of 
Kahlern and Schultze. Laehr, Halin. Dejerine, Bris- 
saud, Schlesinger, and von Soelder have studied in de- 
tail the peculiarities of distribution. Most character- 
istic is the so-called "syringomyelia dissociation" — the 
essential preservation of touch and sense of pressure, 
position, and movement, and more or less complete 
loss of the sense of pain and the temperature sense. 
At times only the temperature sense is involved or the 
perception of heat may be lost and that of cold pre- 
served, or rice versa. Sometimes only extremes of tem- 
perature are confused and moderate degrees are well 
recognized (Dejerine). The distribution of the sen- 
sory loss follows the rules of segmental innervation 
(Laehr) in nearly all cases; in the extremities the loss 
is in bands following the axis of the limb; over the 
trunk the changes occur in zones about the body. 
Even in the trigeminus the segmental type prevails 
(von Soelder). In certain cases, however, the so-called 
"geometrical" distribution of Charcot holds good; the 
analgesia or thermanesthesia affects an entire hand, 
or the entire arm, or the arm and part of the trunk, 
etc. — "sleeve," "cuff," "waistcoat," forms of Char- 
cot. This form exists without complicating hysteria 
(Brissaud, Schlesinger). Even within these plaques 
Laehr has demonstrated a tendency to segmental dis- 
tribution of varying degrees of analgesia or therman- 
esthesia. 

In many cases tactile sensibility is normal, in others 
there are losses over small areas. Deep sensation may 
at times be involved, owing to the existence of pos- 
terior-column lesions. Ataxia is not infrequent. 
Stereognosis is often affected. Surface sensation and 
deep sensation are not necessarily affected to an equal 
degree; there may be loss of pain in deep structures, as 
bones and joints, while the skin sensations over these 
parts may be normal; usually, however, they are in- 
volved simultaneously. Frequently there is loss of 
testicular pain on pressure. The mucous membranes 
are commonly involved. 

Pain is common and often severe; it may be constant, 
boring, not infrequently lancinating; it is felt oftenest 
in the arms and upper tnink; with high seat of the 
lesion there may be occipital neuralgia or obstinate pain 
in the distribution of the triL'eniinus. Paresthesia; 

86 



are usually present, often a feeling of cold or heat, or 
a mixed sensation of "burning cold." The pains and 
parcsthe.-iia' may persist in regions in which there is 
objective loss of sensation. The subjective sensations 
are important in diagnosis as they appear early and 
often call attention to atrophy and objective sensory 
changes. The jiaresthesia' of the temperature sense 
may be extreme and may lead to grave injury through 
the patient's ungoverned use of counteracting heat or 
cold. .Vnalgesia and thermancsth(>sia (li'])ciid on le- 
sions of the central gray matter and adjacent conduct- 
ing paths. It must be remembered that dissociation 
of sensory qualities maj- not be an attribute of syringo- 
myelia alone; it is freciuent in hysteria and may occur 
in brain or spinal-cord lesions or in affections of peri- 
pheral nerves. 

Motor Phenomena. — Atrophy is the symptom of 
chief import. It involves the arms most frequently, 
is often unilateral. The small muscles of the hands 
are most constantly affected. In early stages there 
may be the type of a peripheral median or ulnar lesion, 
manifesting itself in the form of the ape hand or the 
claw hand; combinations of the two are not infrequent. 
More frequent is the simultaneous atrophy of all the 
small hand muscles, the Aran-Duchenne type. The 
process may skip the forearm and spring to the shoul- 
der group. At times all muscles undergo extreme 
wasting. The shoulder muscles may be attacked first ; 
frequently individual bundles undergo atrophy, while 
others remain normal or become hypertrophied. The 
lower third of the trapezius is commonly involved, the 
upper part very rarely. The process is seldom sym- 
metrical. The thorax muscles may be involved 
irreguliirly — primarily or after the arms. The inter- 
costal muscles and diaphragm are usually spared. 
The lower extremities, as a rule, follow the arms in 
point of time. The quadriceps, muscles of the calf, 
and foot extensors are the common seats of atrophy. 
Various forms of club-foot occur. At times atrophy 
is masked by fat or diffuse edema. 

Fibrillary twitching is frequent; it may be an early 
symptom and is often felt by the patient. Tremor, 
choreiform twitching, and other spontaneous move- 
ments occur; they may or may not be limited to 
atrophic muscles, and are often associated with par- 
esthesia; or pain. Tonic cramps occur most often in 
the lower extremities, but they may involve many 
muscles and simulate at times hysterical seizures. 
Gradations toward myotonia have been observed, 
muscles becoming rigid on exposure to cold. The 
myotonic reaction has been observed. Contractures 
are frequent in later stages and may lead to great dis- 
tortion. The gait shows usually a spastic paraplegia; 
ataxia is not infreciuent; cerebellar gait is rare. All 
forms of electric reactions may be demonstrated. 
Often there is only quantitative loss; at times the 
reaction of degeneration may be found in separate 
muscle bundles; at times complete reaction of degen- 
eration is present. 

Trophic Changes. — The manifold trophic distur- 
bances of syringomyelia speak rather for separate 
trophic nerves and centers. Trophic changes may 
exist without demonstrable loss of sensation. It is 
difficult to classify the diverse skin lesions that may 
occur. Peculiarities of sweat secretion are common : 
hyperidrosis, anidrosis, unilateral or regional sweating, 
sweating in response to cold and not to heat. Hy- 
peridrosis may be an early symptom, its distribution 
may correspond to the sensory changes. 

Scars of mjuriesand bums, panaritium (often pain- 
less), eczema, and deep fissures, blisters, erythema, 
urticaria, and pemphigus are frequently seen. 

Thickening of the skin of the palms and of the 
fingers may be extreme. Firm edema of the hands and 
the peeidiar thickening of the hands — the main suc- 
culentr of Marinesco — are not uncommon. 

Scleroderma has been noted in a few cases; Ray- 
naud's symptom-complex is rare, gangrene not un- 






REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



t'ommon. Bedsores may develop in acute cases. 
Keloid is common. The nails are often thick, brittle, 
;ind deformed. Aside from the presence of a tuft of 
iKtir over a spina bifida or a spina bifida occulta, an 
uvergrowth of hair rarely occurs. 

Joint tcnions are most important. They may be the 
earliest symptom; eighty per cent, affect the upper 
extremities. Pain may be a prodrome, but usually the 
developed affection is painless — a striking feature. 
The change in the joint may come on suddenly, with 
large effusion or with marked deformity and grating. 
Tlie changes are due to trophic and not to mere ine- 
dianical influences. Atrophic and hypertrophic forms 
(Hcur. Extreme deformity may result. The finger, 
elbow, and shoulder joints are the usual seats of tro- 
jihic change. The lower extremities are more rarely 
involved. Exostoses about the joints and ossification 
of muscles are not infrequent. Suppuration may 
nrcur. The lesions develop spontaneously or under 
the influence of trauma, which may be slight. 

Fractures of bones may occur spontaneously or with 
insufficient cause. There is a great preponderance of 
forearm fractures. Healing may be long delayed and 
incomplete. Exostoses may form. At times there is 
overgrowth of the bones as a whole or enlargement of 
an entire extremity, or of the hand or foot. Usually 
the enlargements are partial and irregular. They 
may develop quickl.v and be associated with inflamma- 
tion. Hitzig described a case with unilateral bulbar 
lesions and hypertrophy of the face on the same side. 
I have seen great enlargement of an arm due to 
recurrent lymphangitis from panaritium infection. 

Two cases of spontaneous tendon rupture have come 
under my observation: in one there was rupture of the 
long head of the biceps of the right (affected) arm; in 
the other, rupture of the patellar tendon in a lumbo- 
sacral type of the disease. 

Thorax Deformities. — Bernhardt was the first to call 
attention to the frequency of scoliosis and kypho- 
scoliosis. Scoliosis is important as a symptom; it may 
occur early and independently of muscle weakness. 
The kyphoscoliosis occasionally leads to great deform- 
ity. It is most frequent in the dorsal region. Some- 
times there is great tenderness of the spine, which may 
be limited to the extent of the deformity or of the proc- 
ess within the cord. Oppenheim regards the scolio- 
sis as a congenital anomaly in certain cases. 

Spina bifida and spina bifida occulta are not 
uncommon. 

The lliorax en bateau is the name given by Marie to a 
peculiar depression of the upper part of the sternum ; 
it is often associated w-ith subluxation of the clavicles 
forward. 

Hemiatrophy of the face has been reported and 
may or may not be associated with lesions of the 
sympathetic. 

In this connection may be mentioned the peculiar 
irregular or "crooked" look of manj' patients afflicted 
with syringomyelia. This seems to depend on irregu- 
larities of head, face and thorax, on irregular thick- 
ening of soft parts, and on irregular innervation of 
facial muscles. It is important as emphasizing the 
influence of congenital anomalies in the pathogenesis 
of the disease. 

Reflexes. — The arm reflexes are often absent, and 
wlien present they vary with the atrophy or the 
affections of the joints. Increased knee-jerks form a 
cardinal symptom. Clonus is frequent; unilateral 
increase is common; even with lumbosacral localiza- 
tion the knee-jerk is curiously persistent and usually 
increased. Absent knee-jerk is found in association 
with tabes or nerve-root lesions or destruction of 
lumbar centers. The superficial reflexes arc not often 
absent; abdominal and cremaster reflexes are fre- 
quently increased. The Babinski reflex and other 
abnormal plantar reflexes are not constant; their 
absence is not against syringomyelia, even when there 
are marked spastic symptoms. 



■tyrliiEomvella 



Sphincter Disturbances. — The bladder is not gener- 
ally affected early and may never be involved. Sen- 
sibility of the mucous membrane mav be lost and yet 
the function be perfect. Difficulty of starting the urine 
is the usual symptom in the beginning; later there may 
be incontinence. Diabetes may occur in bulbar le- 
sions. Pollakiuria is frequent and may be bothersome. 

Constipation is common, but incontinence of the 
bowels is rare. Sexual and menstrual troubles are 
very rare. 

Bulbar and Cranial Symptoms. — As was stated in 
the previous description, the anatomical process 
may involve nerves from the fifth to the twelfth; 
other cranial nerves may be influenced indirectly bv 
hydrocephalus, tabes, etc. Symptoms on the part of 
the olfactorius and auditory nerves are very rare. 

Taste may be affected, but complicating hysteria 
may be a cause; the affection is usually unilateral. 

Eye symptoms are important. Neuritis and atrophy 
of the nerve are rare occurrences and probably depend 
on hydrocephalus or actual gliomata. The pupils 
are often different on account of lesions of the svmpa- 
thetic. The narrow pupil and narrowed opening 
between the eyelids as well as the retrocession of the 
bulb, are found on the side chiefly affected. Kocher 
has shown that lesions of the medulla and upper 
cervical segments are as competent to produce sym- 
pathetic disturbances as are lesions of the lower 
cervical and first dorsal segments. 

Argyll-Robertson pupils do not belong to syringo- 
myelia; if present, they suggest complicating tabes. 

Nystagmus occurs more frequently than in any 
other nerve lesion except multiple sclerosis. 

Eye-muscle palsies may occur, but, on the whole. 
they are rare. They may be recurrent ; the abducens 
is most often affected. 

Trigeminus lesions are important. Violent neural- 
gias or paresthesias may be the first symptom. Disso- 
ciation of sensation is usual, and the distribution fol- 
lows segmental types. The "parietal-ear-chin" line 
of Kocher marks the upper level of the second cervical 
segment supply. As the proximal trigeminus be- 
comes involved the first sensory loss is in the scalp and 
then in areas narrowing concentrically toward the 
nose (von Soelder, Schlesingef). 

The motor fifth is hardly ever affected. The cor- 
neal reflex is very rarely absent. Occasional trophic 
disturbances occur, such as less of hair or teeth ; or the 
tears may be more abundant on the affected side. 
Implication of the facial is uncommon: most often 
the lower portion is alone affected. Often there is no 
reaction of degeneration. 

Hemiatrophy of the tongue is a frequent and may 
be an initial symptom. Unilateral affections of the 
soft palate and larynx are extremely important in 
diagnosis. In the larynx the usual lesion is paralysis 
of muscles supplied by one recurrent. Sensory and 
motor larj-ngeal changes may be independent of one 
another. It is important to remember that the laryn- 
geal palsies may develop in an apoplectiform manner 
with marked vertigo and even loss of consciousness. 
Vertigo, however, may occur independently of bulbar 
lesions. 

Vomiting may be periodic, occurring in attacks like 
regular tabetic crises. Heart symptoms are rare. 

Headache is not a feature of the disease. Convul- 
sions may rarely occur. Scanning speech has been 
reported in several cases. 

Atypical Forms. — -There may be, for long periods, 
the picture of a spastic paraplegia or an amyotrophic 
lateral sclerosis. Sensory changes may be absent for 
years (Bouchard). Bulbar symptoms may come on in 
an apoplectiform manner and for a long time they may 
be the only manifestations of the disease. In very 
rare cases there may be widespread sensory changes — 
anesthesia as well "as analgesia and thcrmanesthesia. 
In the celebrated case of Spaeth and Schnepprl there 
was practically total loss of all forms of sensation. 

87 



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REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



In l,S,S;j Morvan published desc-riptidiis of a symp- 
toni-coniplox that lias since been known by his name. 
He described the combination of painless panaritium 
of the fingers with tirvtit deformity and with marked 
loss of pain- and temperature-perception in the hands 
and arms. Autopsies of JofTroy-Achard, ProulT. 
Marineseo, Hoffman, Redlich, Schlesinger, and others 
have demonstrated the direct a.ssociation of Morvan's 
symptom-complex with .syringomyelia. On the other 
hand, the same picture may present itself in leprosy, 
and only a careful examination will enable one to make 
u differential diagnosis. 

The early appearance of changes in the joints, 
spontaneous fractures, etc., can lead to confusion only 
on superficial examination. 

DiFt-EKKNTiAL DIAGNOSIS. — There is no doubt that 
syringomyelia represents a clinical if not an anatomi- 
cal entity. Due attention to the combination of sen- 
sory, motor, and trophic changes will usually enable 
one to make a correct diagnosis. The following rep- 
resent the chief conditions that may lead to confusion: 

1. ProgrcxsUe Muscular Atrophy. — Kahler and 
Sehultze pointed out the importance of sensory 
changes in distinguishing syringomyelia from cases of 
muscle atrophy of the Aran-Duehenne type. The 
doubtful eases are those in which, for years, there are 
no sensory changes (Croeg, Dejerine). It is necessary 
to seek for isolated loss or diminution of temperature- 
perception. Increased knee-jerks, scoliosis, lesions of 
the sympathetic, trophic changes, paresthesia;, ataxia, 
sphincter disturbances, speak for syringomyelia. 

2. Amyotrophic Lateral Sclerosis. — Sensory changes 
are rare, but they may occur (Oppenheira). Bladder 
symptoms, scoliosis, paresthesiie, unilateral bulbar 
symptoms, trigeminus involvement, nystagmus, are 
decisive for syringomyelia. 

3. Multiple Sclerosis. — Tremor, nystagmus, scan- 
ning speech, increased knee-jerks, spastic paraplegia, 
ataxia, spliiru-ter disturbances — these are symptoms 
that belong to both diseases. Some sensory change is 
not uncommon in multiple sclerosis, and even dissocia- 
tion may occur (Freuiid, Reichel). Optic atrophy, 
cspcciall}' atrophy of the temporal half, decides for 
multiple sclerosis. Marked sensory changes, muscle 
atrophy, trophic disturbances, scoliosis, speak for 
syringomyelia. Remissions may occur in either 
affection, but are more usual in multiple sclerosis. 

4. Progressive Muscular Dysirnphij. — If syringo- 
myelia begins in the shoulder group of muscles atro- 
phy is not rarely associated witli partial hypertrophy, 
and, if cases of dystrophy are complicated with hys- 
terical sensory changes, the two conditions will appear 
very much alike. Trophic disturbances, increased 
knee-jerks, .segmental sensory distribution, bulbar 
symptoms, decide for syringomyelia. 

' 5. Meningomyelitis Luetica. — Spastic paraplegia 
and dissociation of sensation may occur in both dis- 
eases. Brain symptoms and a Brown-S6c)uard type of 
motor and .sensory lesions favor lues. Scoliosis and 
trophic changes are absent. Nystagmus is very rare. 
Tlie Was.sormann reaction in the serum and cerebro- 
spinal fluid, with increased lymphocyte count, globu- 
lin and gold reactions in the cerebrospinal fluid afford 
most important data in the recognition of spyhilis. 

6. Tabes. — There may be many symptoms in com- 
mon. Strongly characteristic symptoms in either 
direction decide. Thus, for example, the Argyll- 
Robertson pupil, loss of knee-jerk, ataxia, sphincter 
disturbances, character of sensory loss, trophic 
changes in lower extremities, cri.ses, belong to tabes; 
on the other hand, muscle atrophy, marked dissocia- 
tion of sensation over large areas, increased knee- 
jerks, scoliosis, trophic changes in the arms, speak for 
syringomyelia. 

7. Ilcmatomyelia. — In this disease the symptoms 
are marked at first, but later some improvement takes 
place. Syringomyelia is usually steadily progressive. 



K. Plexus Affections. — Cases have been reported of) 
bilateral plexus palsies, of both the Krb and the Klump- 
ke types. There may be dissociation of sensation as I 
in .syringomyelia, and the distribution may be of the I 
segmental type. In some cases only continuefl obser- 
vation will decide; as a rule, tenderness of the nerve 
trunks and of the spine is more marked in the plexus 
affections, there is no increase of knee-jerks, bulbar 
symptoms do not occur, and the losses of sensation are 
limited to the arms. 

9. Hysteria. — Complications with hysteria may add 
to the (lifriculties of differential diagnosis in muscular 
dystrophies, atrophies, etc., as mentioned above; or 
hysteria may be added to or may simulate .some of 
the syinploMis of syringomyelia. In the sensory dis- 
turl):inccs of hysteria dissociation is rarely .segmental. 
Suggestion may lead to disappearance or transference 
<if the sensory losses. Deep or superficial reflexes are 
little modified, trophic changes and atrophies are ex- 
tremely rare. Bulbar changes do not occur. 

10. Extramedullary Tumors ami lyiiiiiliznt Miiiiiujitis. 
— Extramedullary tumors or Imalizc-il t liickining of 
meninges with damming of fluid alni\c, cspcciallx- in the 
cervical region of the cord, may at times give a clinical 
jiicture closely resembling syringomyelia. We know 
from recent reports that these processes may advance 
to high degrees of root and cord compression without 
causing pain. Dissociation of sensation, as in syringo- 
myelia, is rare but it may occur. Atrophy of hand 
or arm muscles, scoliosis, increased reflexes below, ab- 
normal plantar reflexes, ataxia, paraplegia, sphincteric 
disturbances are frequent phenomena. Symptoms 
maj' be unilateral for long periods of time as in 
syringomyelia. It is well to remember the possibility 
of tumor or other causes of compression in all cases 
of atypical cord disease. As a rule the advance of 
symptoms is more rapid in tumor than in syringo- 
myelia. All qualities of sensation are blocked much 
more frequently and the typical dissociation of syrin- 
gomyelia rarely occurs. Cranial nerves are not in- 
volved. Trophic disturbances are rare. Lumbar 
puncture may yield the yellowish fluid of stasis with 
high-globular content. 

11. Central Tumors. — (Tubercle gumma, glioma, 
etc.) Here symptoms are severe and advance quickly, i' 
Pain is severe; marked paresthesiae, especially of heat I 
and cold, are usual; atrophies and paralyses, particu- " 
larly paraplegia, come on rapidly. Ataxia and ' 
sphincter disturbances are frequent; there is often 
complete or partial development of the Brown- 
Sfojuard complex; if bulbar symptoms occur they are 
severe and run their course quickly. 

12. Pemphigus, scleroderma, Raynaud's disease, de- 
formities due to arteriosclerosis, pellagra, and lathy- 
rism, can rarely give rise to confusion. 

13. In coincidence of leprosy and syringomyelia was 
pointed out by Steudener in 1867 and by Laiighans in 
1875, but the publication of Morvan's work in 1883 
first awakened general interest in the question. As 
described above, the Morvan symptom-complex was ; 
shown, by care fully made autopsies, to be associated 
with syringomj'clia (Joffroy and Achard, Prouff, 
Redlich, Schlesinger, and others). But, subsequently, 
Zainbaco published reports which showed that in Brit- 
tany, where Morvan had carried on his work and where 
leprosy was endemic, there occurred cases which 
merited the name of Morvan's disease, but in which 
the existence of leprous neuritis was absolutely proved. 

It is particularly these trophic forms of syringomyelia 
that are liable to be taken for leprosy, and it is equally 
true that the anesthetic and not the tuberculous types 
of leprosy are confused with syringomyelia. Despite 
the views of some extremists, the two diseases are 
undoubtedly distinct. Leprosy has no influence in the 
production of syringomyelia, and unequivocal lesions 
of leprosy have never been found associated with 
syringomyeUa; accidental combination may of course 
be possible. The leprous analgesia or thermo-anes- 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



Tabes Dorsalis 



thesia depends on involvement of peripheral nerves 
and is usually not so widespread nor so segincntally 
distributed as in syringomyelia. Evidence of periph- 
eral nerve disease is found in thickening of nerve 
trunks, particularly the ulna and great auricular. 
Bulbar lesions, increased knee-jerks, girdle sensation, 
sphincter disturbance, and scoliosis do not belong to 
tiie symptomatology of leprosy. On the other hand, 
the cutaneous nodes, widespread pemphigus, vitiligo, 
uliite scars, and, above all, the demonstration of 
bacilli in the blood, nasal secretion, etc., decide for 
leprosy. The Wassermann reaction occurs in leprosy, 
not in syringomyelia. There are some cases, especially 
in districts where leprosy is endemic, in which a 
diagnosis is difficult; as autopsies prove, however, con- 
founding of the two diseases can even then be avoided 
if a careful examination be made. 

Course and Prognosis. — The disease is eminently 
chronic; cases have been known of thirty, forty, and 
fifty years' duration. The type of disease dependent on 
quick glia-prolifcration (gliosis without cavity forma- 
tion) runs a relatively rapid course (from three to six 
years), but the cases can hardly be separated clinically. 

Intercurrent infections and trauma often influence 
tlie process unfavorably. Apoplectiform attacks may 
occur with accentuation of bulbar or spinal symptoms; 
marked remissions also occasionally occur. The bul- 
Ixir lesions are on the whole benignant and may last 
for years unchanged. 

Death may occur from bladder and kidney compli- 
cations, from sepsis following the various trophic dis- 
turbances, and sometimes from bulbar lesions, but 
most often from intercurrent disease. 

Treatment. — From the nature of the lesions it is 
impossible to expect direct results from treatment. 
In a few cases, due seemingly to lues, specific treat- 
ment has proved advantageous. Prophylactic meas- 
ures playan important part. Such are: avoidance of 
trauma, of overuse of atrophic muscles; prevention 
(if bedsores and, to a certain extent, of atrophic joints; 
avoidance of injury to analgesic extremities, and of 
exposure to injurious temperature changes; above all, 
great care in the avoidance of bladder complications. 

Mud baths and gentle massage may help con- 
tractures. 

Electricity, galvanic and static, may relieve pain or 
paresthesia?. Treatment with x-ray, in the writer's 
experience, has been of no value. 

Panaritium and suppurating joints must be treated 
surgically; as a rule, wounds from surgical operations 
heal fairly. Pain may require phenacetin, antipyrin, 
pyramidon, salicylates, or morphine. Potassiimi 
iodide, mercury, and salvarsan should be given in cases 
of questionable luetic orgin, or iodide may be tried for 
a time in all cases. General tonics can be of only in- 
direct service. Herbert C. Moffitt. 



Syrupi. — The title syrupus (a cyrup) is given to 
such fluid preparations of aqueous basis as contain in 
solution notable amounts of sugar, the purpose of the 
sugar being either to flavor or to preserve the prepara- 
tion. The official "syrups" of the United States 
Pharmacopa'ia are quite incongruous. Syrups pre- 
pared from vegetable drugs are, as a class, of com- 
paratively feeble medicinal power, and are prone to 
decomposition by fermentation, but, as an offset, 
are comparatively pleasant of taste. Quite a number 
of vegetable "syrups," indeed, have no other purpose 
than to serve as flavoring ingredients. As such may 
be enumerated the pharmacopocial "syrup," simply 
so called — an aqueous solution of cane-sugar of 
specific gravity 1.313, and the "syrups," respectively, 
of citric acid, almond, orange, orange flowers, wild 
cherry, rose, raspberry, tolu, and ginger. In pre- 
scription a flavoring syrup should, as a nde, not exceed 
one-half the volume of the prescribed mixture. 



Fermented syrups are useless for dispensing purposes. 
There are twenty-nine syrups official in the I nited 
States Pharmacopoeia, and thirtv-nine in the National 
Formulary. ' R. j. r. Scott. 



Tabanidae. — A family of biting flies which includes 
the horse-flies, gad-flies, breeze-flies, etc. About 1,800 
species are known. The blood sucking is confined to 
the females, the males living on plant juices. These 
pests may be killed when they come tn drink by put- 
ting kerosene on the water. A. S! P. 

Tabes Dorsalis. — "Tabes" is the term which has 
been universally adopted to describe the disease 
popularly known as "locomotor ataxia," a name 
originally given to this affection by Duchenne in 1858. 
The latter is objectionable, however, because it is 
merely descriptive of a symptom, which at times may 
not appear until late in the course of the disease, or 
which may be entirely absent. "Posterior spinal 
sclerosis" is also unsatisfactory, as it refers only to 
the most easily discoverable " lesion. "Tabes "dor- 
salis," or "wasting of the back," was applied by 
Hippocrates to certain symptoms supposed to be due 
to venereal excess, but was restricted to this disease by 
Romberg. 

Tabes is the most common form of chronic organic 
disease of the nervous system. The pathological 
process underlying the affection is a parenchymatous 
degeneration terminating in sclerosis, which" princi- 
pally involves the sensory neurones. The i)eripheral 
motor neurones are also frequently implicated. In 
other words, it may be looked upon as a degenerative 
disease affecting various parts of the entire nervous 
system, while the most pronounced and extensive 
lesion is found in the posterior columns of the spinal 
cord. The morbid process may attack the cranial 
nerves and their nuclei as well as the peripheral 
nerves in the extremities. It may thus produce 
blindness from gray degeneration of the optic nerves, 
or paralysis of ocular muscles from degeneration of the 
nerve nuclei. The brain cortex does not always 
escape. The parts first affected in tabes are usually 
the fibers which originate in the spinal ganglia, i.e. 
the fibers of the posterior roots which traverse the 
posterior columns. 

Etiology. — Tabes is now classified among the 
syphilitic diseases of the nervous system, for it has 
been conclusively shown that syphilis is the essential 
cause. This has been determined by the history of 
luetic infection, and the results of examination of the 
blood and cerebrospinal fluid. Modern serological 
methods have shown a positive Wa.sscrmann reaction 
either in the blood serum or in the cerebrospinal 
fluid; more frequently in the latter, which also often 
shows an excess of globulin, and an abnormal number 
of lymphocj-tes to each cubic millimeter of cerebro- 
spinal fluid. In many cases, either sexual excesses, 
exposure to cold, overfatigue or trauma may act as 
an exciting or precipitating cause of the manifestation 
of the disease, which hitherto had been latent or 
undiscovered. 

Symptoms. — Among the early symptoms of the dis- 
ease first noticed by the patient are pains in the trunk 
and extremities; disturbance of the bladder; impo- 
tence; rectal pain; diplopia; ocular paralysis; failing 
vision; cutaneous hyperesthesia or anesthesia; inco- 
ordination in walking; visceral symptoms known as 
"crises" affecting the gastrointestinal tract, bladder, 
or rectum, and occasionally laryngeal "crL-ses." 

Pain is often one of the earliest symptoms of tabes, 
and may antedate all other symptoms for many years. 
The character of the tabetic pains is as a rule pathog- 
nomonic. They are irregular in their distribution 
and are usually described by the patient as "shock- 

89 



Tabes Diirsalls 



REFERENCE IIANDBOOK OF THE MEDICAL SCIENCES 



like," "shiirp," "piprcinfs," "cutting," or "stabbing," 
being rapidly repented at the same spot, which often 
becomes extremely sensitive to the slightest touch. 
They may also resemble the painful sensation as if 
the muscles and bones were being crushed, or as if a 
piece of nerve was pulled. They may be so sudden in 
their onset that a strong man is surprised into a loud 
exclamation of pain while feeling otherwise well. 
They may occur every few moments for minutes, 
hours, or days. Although they differ essentisiUy 
from true neuralgic, muscular, or periosteal pains, 
they are often erroneously considered as being of such 
origin. Hence it is a common experience for the iicu- 
roiogi.st to receive such patients with their announce- 
ment that they had previously been under treatment 
for rheumatisn'i or neuralgia. In order fully to appre- 
ciate the significance of these pains, it is necessary to 
study this symptom carefully and minutely, for it 
may exist for several years before other symptoms are 
at all prominent. In the majority of instances, the 
pains most frecjuently affect the lower extremities. 
They may, however, be limited to the inframammary, 
intercostal, dorsal, or lumbar regions. Indeed, they 
are known to attack almost any part of the body. 
They may thus appear iti the form of trigeminal facial 
pain or be located in the scalp. On the other hand, 
in some patients, pain is eit her entirely absent or only 
a slight, dull, circumscribed, and aching pain is 
occasionally complained of. If such pains do not 
appear in the early period of the disease, they are 
not likely to ap|)ear later. 

Crineri. — -At almost any stage of the disease suddenly 
recurring paroxysmal attacks of severe gastralgia may 
take place, accompanied by exhaustive vomiting, 
which resists all ordinary methods of treatment, but 
seems to subside spontaneously. These attacks are 
known as "giistric crises." Sometimes persistent 
gastralgia may be the only symptom complained of. 
In such a case careful examination will often reveal 
an area of cutaneous anesthesia in the epigastric 
region, thus leading to further investigation which 
discloses the underlying cause of the pain. Instead 
of these "gastric crises," there may be severe and 
unaccountable diarrhea associated with violent 
colicky pain that may sometimes simulate an attack 
of renal colic. In some instances the rectum may be 
the seat of severe pain that is remittent in character. 
This pain not being relieved by ordinary means, its 
true nature being overlooked, surgeons have been led 
to the fruitless operation of forcibly stretching ancl 
paralyzing the anal sphincter and removing any 
licmorrhoids that perchance are present. 

"Laryngeal crises" occur only in a very smaU pre- 
centage of cases. The most common form is true 
laryngeal spasm, with noisy inspiration and expiration, 
cough, ancl often considerable dyspnea. The parox- 
ysms may resemble those of whooping-cough or of 
laryngismus stridulus. Death during these attacks 
is extremely rare. 

Incontinence or retention of urine is frequently an 
early symptom. Considerable effort is required in 
micturition, the urine flowing slowly. Quite often 
the bladder is not completely emptied and the residual 
urine may undergo decomposition and thus set up a 
cystitis. 

Impotence may .also occur as an early manifestation, 
I)ut it usually develops as the disease advances. 

Diplopia, ocnlar pardb/s-is, or failing insion may be 
the first symptom that leads the patient to consult a 
physician. For several years before other symptoms 
are clearly manifested, or at any time in the early 
period of the disease, there may be frequent diplopia, 
or transient attacks of paraly.sis affecting the ocular 
muscles; the.se attacks are of nuclear or peripheral ori- 
gin. The paralyses of the external ocular muscles are 
often bilateral, but not symmetrical, often unilateral, 
and frequently affect only single muscles. Ptosis and 
paralysis of one or more muscles supplied by the ocu- 

90 



lomotor nerve, and abducens paralysis, are the mo.st 
frequent. As a rule they develop suddenly and usu- 
ally disappear after a longer or shorter period, with or 
without treatment. Relapses are frequent. Attention 
may first be drawn to the disease through a sudden 
third- or sixth-nerve paralysis, either partial or com- 
plete. The duration varies from a few hours to a year 
or more, or the paralysis may become permanent. 
Sometimes both eyes are affected, and a progress- 
ive and complete ophthalmoplegia may ultimately 
develop. 

Atrophy of the optic nerve is the most serious ocular ■ 
complication of tabes. It occurs in about ten or 
fifteen per cent, of the cases. For a long time it may 
be the only symptom of the disease, thus appearing 
several years before other characteristic phcnomen.a 
are manifested. It rarely develops in the later period 
of the disease. The atrophic process is the result of 
gray degeneration of the optic nerves similar to that 
which attacks the posterior column of the spinal 
cord. The failure of sight usually commences with a 
peripheral limitation of the field and loss of color vision 
(the visual field for green contracting early) ; but 
sometimes central vision is defective from the very 
beginning. The atrophy is almost always bilateral, 
being more advanced in one eye than in the other, and 
ultimately progresses to complete blindness. It is 
rare for tabetic patients who become blind at an 
early stage of the disease to become ataxic later; but 
if the ataxia has become well pronounced, it does not 
always improve with the subsequent development 
of optic atrophy. In the majority of instances, the 
occurrence of optic atrophy seems to inhibit the 
further progress of the disease. This is a peculiar 
clinical fact which has never been satisfactorily 
explained. 

Incoordination, or ataxia as it is familiarly termed, 
is a common symptom in many cases of tabes and most 
frequently affects the lower extremities. It has oc- 
casionally been noted by the patient himself, who first 
discovers difficulty in standing or walking with 
closed eyes. 

As a rule, the lower extremities are affected first. 
When the sclerosis begins in the cervical portion of the 
cord, the ataxia, as well as other symptoms, may, for a 
longer or shorter period, be confined to the upper 
extremities. It is a curious clinical fact, previously 
mentioned, that, in cases in which optic atrophy 
appears, the ataxia often ceases its further progress. 

Incoordination is a disturbance of the associated 
muscular action which is essential in the maintenance 
of equilibrium. Coordinate muscular action is kept 
under the patient's control to a certain extent by the 
attention and vision. As soon as the patient fails 
to watch his movements, or the eyes are closed, the 
ataxia is materially increased and may become un- 
controllable. Thus, while standing with closed eyes 
and the feet close together, he may gradually or 
suddenly fall to the ground (static ataxia), being 
deprived of the sense of position of the legs, vuiless 
the eyes are opened. Incoordination affecting the 
lower extremities is productive of the characteristic 
tabetic gait ("locomotor ataxia"). In attempts 
at walking, w-hen the condition is well pronounced, 
the foot is lifted from the ground at a much higher 
elevation than normal, and, being poised with con- 
siderable uncertainty, it is suddenly brought to the 
ground, striking forcibly on the heel. 

The ataxia is due to an obstruction or obliteration 
of afferent impulses conducted from the periphery 
through the various sensory tracts. It therefore 
follows as a result of sclerosis of the posterior columns 
of the cord, or of degeneration of the peripheral 
sensory fibers in the muscles and joints, being directly 
conditioned by a loss of muscle and joint sensibility. 

While in some cases it is often the most striking 
symptom, occasionally developing during the first 
years of the disease in conjunction with other dis- 



REFERENX'E HANDBOOK OF THE MEDIC.\L SCIENX-ES 



Tabes Dor»sll!i 



covemble signs, in many instances the ataxia is 
scarcely perceptible or demonstrable, or does not ap- 
pear at all at any time during the course of the malady. 
Hence the designation of the affection as "locomotor 
ataxia" is a misnomer. 

Sensory Disturbances. — Various paresthesise are 
ifrrn complained of, such as numbness or formication 
111 the extremities — a sensation as if the soles of the 
feet were resting upon rubber or fur; a band-like feel- 
ing around the body, usually at the level of the mid- 
thoracic region, as if a tight corset or belt enveloped 
the body. This sensation is known as "cincture 
feeling" or "girdle sensation." Or the patient 
discovers that sensibility in his legs is absent in various 
.iioas. In the upper extremities there may be numb- 
iit'ss in the course of the ulnar nerve affecting espe- 
nally the fourth and fifth fingers. In addition to the 
pains and paresthesije described by the patient, 
disturbances of cutaneous sensibility are often found 
upon examination, in association with the loss of 
muscle and joint sensibility just mentioned. Im- 
pairment of sensation may be entirely absent, but in 
most cases of tabes some objective sensory disturbance 
is always found. It may vary from slight diminution 
of tactile sensibility to the most pronounced analgesia. 
The different cjualities of sensation should always be 
tested carefully. In a large percentage of tabetics 
(four-fifths) there is an area of diminished sensibility 
to touch situated like a band about the chest in the 
midthoracic region and varying from three to four 
inches in width. This tactile loss may be associated 
with analgesia in the same area. A diminution in 
the sense of touch, pressure sense, and the sense of 
position of the limbs, usually appears in the early 
stage, whUe the higher degrees of anesthesia are 
developed later. The temperature sense may remain 
unimpaired until the last stage of the disease. But 
analgesia is one of the earliest and commonest forms 
of sensory disturbance. The areas of analgesia may 
be distributed over the trunk and extremities. In 
the lower extremities it involves the sole of the foot, 
the heel, the toes, the anterior or lateral portions of 
the legs, or the inner surface of the thigh. The 
transmission of painful sensations is retarded in some 
cases, the prick of a needle being interpreted at once 
as a touch, and recognized as a painful sensation from 
three to ten or fifteen seconds later. This is generally 
described as "delayed conduction." 

The loss of joint sensibility and of the sensibility of 
the deeper muscular structure occasions interference 
with the normal muscular "tonus" and results in 
deficienc}- or complete relaxation of muscular tension 
(hypotonus). This condition will explain the fact 
why tabetic patients submit to extreme passive move- 
ments of the extremities without complaint of pain. 
It may also account for the occurrence of hyperexten- 
1 111 of the knee-joints often seen in tabetics (genu 
' f urvatum). 

Although patients often complain of weakness in 
the legs, it is only in exceptional instances (in which 
the motor neurone system becomes implicated) that 
such condition can be actually demonstrated. As a 
rule, the muscular power and resistance to passive 
movement are unimpaired. When muscular atrophy 
or actual paralysis exists, they must be considered as 
complications arising in the course of the disease. 

Loss of the Knee-jcrh. — One of the earliest and 
most constant objective signs of tabes is the loss of 
the knee-jerk. As a rule it does not disappear 
suddenly. The pains may exi.st for a long time before 
the knee-jerk disappears". In the study of a large 
series of cases the knee-jerk symptom is found to be 
variable in its character. In quite a nuinl)er of 
nstances of undoubted tabes both knee-jerks may bo 
ictive, but they usually disappear as the disease ad- 
••ances. This occurs when the upper portion of the 
■ord is first affected. In other cases, the knee-jerks 
uay be well marked on one side and lost on the other. 



.Vgain, they may be apparently absent, but demon- 
straVjle only upon so-called reinforcement. Both 
may be equally feeble, or may differ in degree of 
weakness. 

It has been claimed that in about one per cent, of 
healthy people the knee-jerk is absent. The correct- 
ness of this assertion is questionable. Such an 
anomaly is so rare that its possibilitv need only be 
remembered. The writer has tested over 1,000 
healthy children from three to fourteen years of 
of age, and the knee-jerk was demonstrable "in every 
case. Its absence is due to an interruption in the 
so-called reflex arc in relation with the corresponding 
center situated in the lumbar region of the cord. 
Much patience is often required in satisfactorily 
determining whether the knee-jerk is present or 
absent. The ordinary and customarv method of 
testing for the knee-jerk while the person's legs are 
crossed, or the feet resting on the floor, will isuffice 
when the knee-jerks are quite active. Under such 
circumstances the position of the limbs is immaterial. 
The utmost care, however, is necessarj' when there is 
any doubt as to the presence of the reaction. It 
will then be advisable to have the patient sit upon a 
high chair or upon the edge of a table, so that the feet 
are free from the floor. As a rule, both sides should 
be examined. In many instances the anticipation of 
the tap upon the tendon occasions involuntary rigidity 
of the flexor group of muscles, thus producmg sufficient 
opposition to overcome the action of the quadriceps. 
Hence, before and during the examination, the 
patient should close his eyes, and his attention 
should be directed from the purpose of the examiner, 
either by conversation or by rapid interrogation. Or 
he may be directed to make some muscular effort with 
his hands, such as forcibly interlocking the fingers, 
elevating the arms, etc. This is known as "re- 
enforcement." With this object in view any other 
similar expedient may be resorted to that suggests 
itself to the examiner. It is never safe to state that 
the knee-jerk is absent, unless repeated and varied 
test have been made with the clothing remt)vcd. 

Loss of the Achilles Keflex. — This may take 
place prior to the loss of the knee-jerk, but, when the 
latter is lost, the Achilles reflex is also unobtainable. 
The ankle-jerk or Achilles reflex is best demonstrated 
by placing the patient in a kneeling position upon a 
chair or table. When the Achilles tendon is struck 
with a percussion hammer, the normal reaction is 
the production of sudden dorsal flexion of the corre- 
sponding foot. 

Keflex Iridoplegia. — Another early and most im- 
portant evidence of tabes is the loss of the reflex 
action of the iris to light. This is familiarly known as 
the "Argyll-Robertson symptom," but in recent 
years it is more correctly described as reflex irido- 
plegia.* It is present in about eighty per cent, of 
all cases. Being a phenomenon somewhat analogous 
to that of the loss of the knee-jerk, it is found to be 
just as variable in the extent of its manifestations. 
Its absence, however, does not exclude the diagnosis 
of tabes. The longer the duration of the disease, the 
more likely are we to find this sign. When present 
it is generally bilateral. In rare instances it is 
unilateral — i.e. affecting only one eye, or the degree of 
reaction may differ in the two eyes. It is usually 
unaccompanied by any disturbance of vision. As a 
rule, the pupils react in convergence of the optic axes. 
In some cases of tabes the pupils are absolutely rigid, 
and do not react to light or in convergence. They 
may also be unequal, partly dilated or contracted. 
The inaction of the pupil when expo.sed to light is not 
indicative of a lesion in the spinal cord, as was errone- 
ously supposed bj' many before tabe^ rested upon a 

• Argyll-Kobertson in his oriRinal paper described the condition 
at a loss of pupillary reaction to light, its prejicr^Tition on convcnr- 
ence, and its acconipaniment by myosis. EJinbutvh .l/rd. Journal, 
vol. I^•., lSti9, p. 487. 

91 



Tabes Uorsalls 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



firm pathological basis, but is tlie result of interference 
with the retk'X conducting jiath in its course between 
the optic nerve, corpora tiuadrigemina, and oculonio- 
torius. It is, tliercforc, due to a lesion within the brain 
and may be looked upon as an almost infallible 
sipn of central nerve depeneration involving the 
sphincter nuclei of the third nerve or their cflferent 
fibers when the eyes are otherwise ajjparently normal. 

The examination of the pupils for reaction to light 
requires the closest observance in its performance. 
This apparently simple procedure is deserving of 
careful attention, and certain precautions are ab- 
solutely essential in order to avoid erroneous conclu- 
sions. " The following method should be pursued: 
Place the ])aticnt in a position facing a window. Day- 
light is always preferable. Instruct him to gaze 
steadily upon some large object at least twenty feet 
distant, and to keep both eyes open. The eyes are 
then covered or shaded either with the examinex's 
hands or with two ])ieces of dark card-board. The 
patient in the mean time must continue gazing in the 
direction just mentioned. In a few moments one eye 
is suddenly uncovered and exposed to the light, w-hen 
in the normal state the pu|)il (which always dilates in 
darkness or subdued light ) immediately contracts. 
The other eye is then tested in the same manner. 
In recent years it has been customary to use a small 
portable electric lamp for this purpose. This flash 
light is very convenient. The patient's face should 
be in the shade, and each eye tested separately. 
The next step is to note if the pupils contract in con- 
vergence or accommodation. After the patient 
has been looking in the distance for a short time, with 
both eyes uncovered, lie is suddenly told to look 
at the examiner's finger, or some small object held 
within two inches of the patient's nose. In the normal 
condition the eyeballs converge and the pupils 
contract. The pupillary reactions should not be 
tested before a gas flame, as the patient is apt to, and 
in fact generally does, "fix" upon the (lame, thereby 
causing contraction of the pupils in accommodation 
and convergence, which may easily mislead. A very 
common source of error to be guarded against, which 
is similar in its result, is the failure to bear in mind the 
natural tendency of the patient to look at the examiner 
as soon as the eye is uncovered. Bilateral reflex 
iridoplegia may also be associated with myosis. 
While the former often exists without the latter, 
myosis is as a rule accomiianied by loss of the pupillary 
light reflex. The myosis, however, is due to a lesion 
affecting the spinal cord and involving the so-called 
cilio-spinal center situated between the fourtli 
cervical and the second dor.sal segments. As the 
pupil-dilating fibers pass from thence out by the rami 
commuiiicantes into the cervical sympathetic, de- 
generation of these fibers causes the permanent con- 
traction of the pupils. 

Arthrnpathy. — Trojjhic disturbance in the bones and 
joints is an occasional phenomenon of tabes, but it is 
of sufficiently frequent occurrence (in about three or 
four per cent, of all cases) to command attention. 
This form of joint affection is known as "tabetic 
arthropathy," and mo.st commonly involves the knee- 
joints, although the hip-joint and the large joints of 
the upper extremities may also be -similarly affected. 
It has often been known "to arise during the early or 
pre-ataxic stage of the di-sease. Painless swelling and 
complete disorganization of the joint are pathogno- 
monic of tabetic arthropathy. It usuallv arises 
suddenly and develops rapidly. Sometimes "following 
a trivial injur}-, the joint becomes swollen and the 
surrounding tissues edematous, but there is complete 
freedom from pain, redness, or fever. The joint 
structures, including the ends of the bones, undergo 
rapid destruction. 

The long bones at times become brittle and thus 
easily fracture either spontaneously or from a slight 
traumatism. Among the trophic cutaneous disorders, 

92 



perforating ulcer of the foot is the most common. 
It is usually situated on the plantar surface of the foot, 
either under the base of the great toe or of the fifth 
metatar.sal bone, or at the heel. It generally begins 
as a callus or corn, and is painless, even when the 
ulcerative process is quite deep and extensive. 

Diagnosis. — The appearance of a classical ease of 
the well-advanced disease, as described in the text- 
books, is a familiar picture. There is a superabun- 
dance of convincing proof to establish the fact that 
this, probably the commonest form of organic nervous 
disorder, often remains unrecognized for months or 
jears during its early stages, although am])le evidence 
of its presence may be discoverable by proper methods 
of investigation. To the most sanguine neurological 
mind the approach of the medical millennium does 
not imply the restoration to life and normal function 
of sclerosed and destroyed nerve .structures; but if 
our modern therapeutic measures are to prove curative 
in this disease, they must be utilized before organic 
changes are too far advanced. Our only hope of 
success in the treatment of tabes rests in a correct 
diagnosis at the earliest possible moment. The early 
diagnosis of tabes — -which, so to speak, is chronic from 
its very beginning — is of incalculable value, inasmuch 
as it saves the patient much misdirected and useless 
medication. When unrecognized tabes has existed 
for some time, various pronounced symptoms may 
appear, and, although a part of the disease, maj- con- 
ceal its true character. Its pre.sence is frequently 
unsuspected by the attending physician until the 
signs are so conspicuous that they almost speak for 
themselves. Although static ataxia frequently occurs 
in tabes, it is by no means pathognomonic. The fact 
that a slight swaying is of common occurrence in 
healthy individuals should always be borne in mind. 
Static incoordination is often present in hysteria or 
pronounced neurasthenia, during convalescence after 
prolonged illness, in transverse myelitis, and in poly- 
neuritis resulting from diphtheria, alcohol, lead, 
arsenic, etc. Some forms of alcoholic polyneuritis 
are commonly mistaken for tabes on account of their 
resemblance to that affection (see the sections on 
Neuritis and Polyneuritis in the article on Xeiiritis). 
Upon superficial examination the presence of static 
ataxia with anesthesia and absence of the knee-jerk, 
points to tabes. But as these symptoms are usually 
associated with tenderness on pressure over the 
affected nerve trunks, diminished muscular power or 
actual paralysis, and decrease or loss of faradic irri- 
tability in the affected muscles, we are enabled to 
exclude tabes. The absence of the knee-jerk in these 
cases is due to involvement of the motor fibers of the 
anterior crural nerve or its branches, and is usually 
an accompaniment of weakness or diminished resist- 
ance in the quadriceps. The loss of the knee-jerk 
in uncomplicated cases of tabes, however, is attended 
as a rule with preservation of muscular power in the 
extensor group, even when the disease is well advanced 
and there is pronounced incoordination. This pecu- 
liar feature of tabes can be easily demonstrated, and 
in my experience is of extreme value. When the 
peripheral sensory nerves are especially affected, as 
in certain forms of toxic polyneuritis, particularly 
from arsenical poisoning, the disease has been termed 
pseudo-tabes. On account of the presence of well- 
marked ataxia, absence of the knee-jerks, and anes- 
thesia, it closely resembles the true disease. A con- 
sideration of the antecedent history, mode of onset, 
and development will generally enable us to reach a 
satisfactory conclusion as to the nature of the trouble. 
At times the differential diagnosis between tabes and 
some atypical forms of polyneuritis is attended with 
much difficulty. On the other hand, in some tabetic 
patients the peripheral nerves of the lower extremities 
may undergo degeneration, and thus lend confusion 
to the otherwise stereotyped picture. I have re- 



REFERENCE HANDBOOK OF THE MEDIC.U, SCIENCES 



Tabes Dorsalls 



peatedly seen chronic transverse dorsal myelitis 
mistaken for tabes, owing to pain in the lower ex- 
tremities, inability to stand with closed eyes, and 
cutaneous anesthesia. Such an error must be as- 
cribed to gross carelessness or neglect in the examina- 
tion. The exaggerated knee-jerks with probable 
ankle clonus, and the loss of muscular power sometimes 
with atrophy, should serve to make the diagnosis 
clear. Some cases of cerebrospinal s^-philis so closely 
simulate genuine tabes that their differentiation can 
be accomplished only after a careful study of the 
development and course of the symptoms. Paretic 
dementia and tabes are sometimes found associated, 
but when the mental symptoms predominate, such as 
( hanges in the patient's character, diminution of the 
intellectual functions, speech disturbances, attacks 
nf imconsciousness, etc., we must favor the diagnosis 
uf the former. 

The most important subjective symptom is the 
pfculiar paroxysmal pains, while the two principal 
objective signs of tabes are the absence of the knee- 
jerk and the loss of the pupiUarj- light reflex. It may 
be safely said that the coexistence of the latter is 
equivalent to the diagnosis of tabes. It rarely 
happens that both are absent at the same time, yet 
such cases do occasionally occur. We must then 
depend upon the association of other symptoms and 
must watch for further developments. The presence 
of either one, in conjunction with the fulgurating 
pains, or bladder disturbance, or the areas of anes- 
thesia over the back, is sufficient evidence to warrant 
the diagnosis. When a man over thirty years of age, 
with a history of ancient sj-philitic infection, com- 
plains of the pains characteristic of tabes, we should at 
once suspect its existence, whether other signs are 
present or not. Should these t>-pical pains be as- 
sociated with one or more of the objective symptoms, 
the diagnosis may be made with confidence. The 
serological and cytological study of the blood and 
cerebrospinal fluid are always essential, and usually 
conclusive. It is a fact well known to all neurologists, 
that among physicians in general the failure to 
recognize the presence of tabes is more common 
than its diagnosis. On the other hand, an incorrect 
inteqiretation of phenomena which resemble those of 
tabes is of frequent occurrence. Such conditions can 
be obviated only, first, by a clear conception of the 
clinical peculiarities of the disease; second, by a prac- 
tical familiarity with the method of examination, 
combined with its application to the individual case. 

I>rR.\Tiox, Course, axd Prognosis. — Tabes is not 
invariably progressive in character, but it is always 
chronic in its course, the average duration of the 
disease being about ten years, although in uncom- 
plicated cases it has frequently lasted for from twentj' 
to thirty years. In rare instances it is very rapid in 
its progress, terminating fatally in a few years. As 
the clinical tj-pes differ materially, the course and 
duration of the disease vary with the character and 
severity of the symptoms. Remissions have been 
known to occur, and under suitable management the 
disease often becomes stationary in its early stages. 
Occasionally, even in well-advanced cases, the amount 
of improvenietvt is often ven,- great. The develop- 
ment of cystitis may at times lead to fatal pyelone- 
phritis, and falls or slight injuries may result in 
fractured bones or in a rapid advance of the patho- 
logical process. The characteristic pains, slight 
ataxia, and absence of knee-jerk and pupillarj- light 
reflex may e.xist for many years without any further 
manifestations. In some cases the symptoms are so 
moderate that the patient may live in comfort and be 
able to be about for many years, while in others the 
mtensity of the symptoms may be so pronounced 
that the patient becomes bedridden in a year or two. 

Treatment. — Although the tabetic degeneration 
cannot be cured, much can be accomplished by im- 



provmg the general health of the patient, and thus, in 
many instances, delaying the further progress of the 
disease. Hence such measures as prolonged rest in 
bed, if necessary, judiciously applied hvdrotherapy, 
massage, and static electricity often prove valuable. 
It is essential to avoid fatiguing exercise or excesses 
of any kind. Certain subjective symptoms may also 
be relieved. Objective symptoms, such as optic 
atrophy, reflex iridoplegia, and absent knee-jerks, 
always remains permanent despite any form of treat- 
ment. The effect of drugs on the tabetic process is 
very misleading on account of the spontaneous remis- 
sions that are known to occur in the course of the 
disease. Besides, the result of the administration of 
medicinal remedies in a given case cannot be pre- 
dicted upon the basis of its beneficial influence in 
another patient. As the disease varies in its type in 
different individuals, the plan of treatment will have 
to be modified accordingly. The patient should be 
cautionecl to avoid any unnecessary exposure to falls 
or other injuries, for the osseous structures are often 
brittle and fractures are easily produced. The condi- 
tion of the bladder must be carefully watched and the 
urine frequently examined. At the first indication 
of decomposition of residual urine, or of any symptoms 
of cystitis, the bladder should be irrigated and the 
patient instructed in the aseptic use of the catheter. 

The intravenous administration of salvarsan or 
neosalvarsan, together with the use of mercury either 
by inunction or intramuscularly, should be sys- 
tematically and persistently carried out according' to 
the judgment of the phy.sician and the laboratory 
report upon the condition of the cerebrospinal fluid. 

The clinical manifenlalions should always be the 
principal guide in the regulation of the treatment. 

Tabetic patients who have never received antiluetic 
treatment since tabetic symptoms have developed, 
should be given a thorough course of active medica- 
tion for several months. If this has already been 
carried out without relief, it is useless — nay, even 
harmful — to repeat the procedure. 

Pain. — If the action of the bowels is regulated and 
the diet and general habits of the patient are properly 
controlled, the frequency and severit}' of the tabetic 
pains will be invariably ameliorated, or the attacks 
maj- subside entirely. The faradic wire brush, or 
linear cauterization applied over the vetebral column 
in the region corresponding with the posterior roots 
that are presumably associated with the location of 
the pain, often proves effective. Various anodyne 
liniments, or the application of an ice-bag or of hot 
water to the seat of the pain during the attack, pve 
relief in some cases. When necessary, the vanous 
coal-tar products may be tried. The most useful are 
acetanilid, phenacetin and pyramidon. As a last 
resort codeine or morphine may be administered. 
During a "gastric crisis" the best method of relief is 
the subcutaneous injection of morphine or codeine. 

Suspension. — This is often useful in selected cases, 
but it should never be used indiscriminately. The 
patient m^iy be suspended in a Sayre apparatus for 
about two or three minutes twice a week. The same 
result (i.e., .stretching of the vertebral column) may 
be accomplished by having the patient sit on the 
floor, and then forcibly flex the head and trunk upon 
the thighs, while the lower extremities are kept 
straight. 

Educational Exercises for Controlling the Ataxia. — 
This plan of treatment was introduced to the medical 
profession in the year 1S89 by Dr. H. S. Frenkel. of 
Heiden, Switzerland. A large variety of exercises 
may be practised. They may be executed with the 
patient in a recumbent position; while sitting; in an 
erect position ; and various movements may be carried 
out while walking. 

Exercises for the Trunk and the Lower Extremities. 
— While recumbent: (a) Lying on the back, raise 
body into sitting position and return to recumbency. 

93 



Tabes Dorsalis 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



(6) Flex thigh upon abdomen, leg upon thigh, tlicn 
extend and elevate entire extremity and slowly return 
to original position, (c) Elevate entire extremity 
while in extension and return (Coldscheider). 

The following movements have been recommcndcil 
by Dana as a modification of Frenkel's method: 

" 1. Sit in a chair, rise slowly to erect position, witli- 
out help from cane or arms of chair. Sit down slowly 
in the same way. Repeat once. 

"2. Stand with cane, feet together; advance left 
foot and return it; same with right. Repeat three 
times. 

"3. Walk ten steps with cane, slowlj-. Walk back- 
ward five steps with cane, slowly. 

"4. Stand without cane, feet a little spread, hands 
on hips. In this position flex the knees, and stoop 
slowly down as far as possible; rise slowly; repeat 
twice. 

"5. Stand erect, carry left foot behind and bring it 
back to its place; the same with the right. Repeat 
three times. 

"6. Walk twenty steps, as in exercise No. 3; then 
walk backward five steps. 

"7. Repeat exercise No. 2, without cane. 

"8. Stand without cane, heels together, hands on 
hips. Stand in this way until you can count twenty. 
Increase the duration each day by five, until you can 
stand in this way while one hundred is being counted. 

"9. Stand without cane, feet spread apart.; raise the 
arms up from the sides until they meet above the 
head. Repeat this three times. With the arms 
raised above the head, carry them forward and down- 
ward, bending with the body until the tips of the 
fingers come as near the floor as they can be safely 
carried. 

" 10. Stand without cane, feet spread apart, hands 
on hips; flex the trunk forward, then to the left, then 
backward, then to the right, making a circle with the 
head. Repeat this three times. 

"11. Do exercise No. 9 with heels together. 

"12. Do exercise No. 10, with heels together. 

"13. Walk along a fixed line, such as a seam on the 
carpet, with cane, placing the feet carefully on the 
line each time. Walk a distance of at least fifteen 
feet. Repeat this twice. 

"14. Do the same without cane. 

"15. Stand erect with cane; describe a circle on the 
floor with the toe of right foot. Same with toe of 
left. Repeat twice. 

"Between the fifth and sixth exercises the patient 
should rest for a few moments." 

All exercises must be performed slowly and deliber- 
ately and repeated several times according to the 
amount of fatigue produced. Some of the principal 
movements have just been described. Many modifi- 
cations or additions may be followed, according to the 
condition of the patient. For more elaborate details 
relating to all forms of exercises for the upper and 
lower extremities, the reader is referred to Frenkel's 
book on "The Exercise Treatment of Tabetic Ataxia." 

A.S all tabetic patients are not ataxic, ^nd as all 
ataxic tabetics are not suitable subjects for such 
exercises, this method of re-educating the cerebral 
centers for coordination will be found to have well- 
defined limitations. Great care and watchfulness 
are necessary in carrying out this plan of systematic 
exercise, particularly in advanced cases. Unle.ss 
practised persistently and systematically, preferably 
under the immediate supervision of a competent 
attendant, the results are usually unsatisfactory. 
Under suitable conditions, patients who were formerly 
unable to stand without assistance have been enabled 
to walk. William M. Lesztnsky. 



Tablet Triturates. — These are a form of medica- 
tion consisting of a solid disc of small and convenient 
size, made of some material at once soluble in water 



and medicinally indifferent, and charged with a 
specified dose of some active medicinal substance. 
Powdered sugar is the base generally employed. Tab- 
let triturates differ from lozenges in that the latter 
contain some mucilage or other adhesive material, 
whereas no such substance is used in tablet triturates. 
These tablets were introduced about forty years ago, 
by Dr. Robert M. Fuller, of New York, and they 
rapidly became a favorite means of administering 
medicines. Special apparatus is required for their 
manufacture, and they have the disadvantage of 
being liable to disintegration by mere contact with each 
other or with the container. Tablet triturates are not 
official in this country, but the 1910 edition of the 
U. S. P. (published in 1916) contains Toxitahellw 
H ydrargyri Chloridi Corrosivi, or Poison Tablets of 
Corrosive Mercuric Chloride. Each of these tablets 
is of an angular shape (not discoid), and has the word 
"Poison" and the skull and cross bones design dis- 
tinctly stamped upon it. R. J. E. Scott. 



Tacoma, Washington. Situated on a peninsula 
extending into Puget Sound, Tacoma, a city of^ 
102,500 inhabitants, is surrounded on three sides — the* 
north, east, and west — by water, while on the south is 
a vast open country called the "Prairies," beyond 
which rises the stately snow-capped Mt. Tacoma, 
affording a striking view from the city. The body of 
water to the east of the city is known as Commence- 
ment Bay, which forms the harbor, and on the tide 
lands of this bay are the wharves and terminals. On 
the west side is the "Narrows," an arm of the Sound. 

The situation of the city, as can well be imagined 
from the above, is strikingly attractive, an attractive- 
ness whicli is enhanced by the environment. The 
"town site is high above the water level, the shore line 
being a series of bluffs, notched with deep ravines. 
The main portion of the city is level." 

Being only thirty-three miles south of Seattle and in 
the same climatic district, the climate of Tacoma is 
essentially the same as that of the former city, to 
which the reader is referred for the climatic data. 
Suffice it to say, that the climate of Tacoma is a mild, 
equable one with moderate temperature at all seasons 
of the year. 

The annual mean temperature is 50.4°; spring, 49°; 
summer, 62.7°; autumn, 51°; winter, 40.7°. Only 
exceptionally does the mercury go below the freezing 
point in winter, and flowers are said to bloom exeTv 
month in the year. In summer the normal temper- 
ature is below 70°. 

The average precipitation is 45.41 inches, a little 
more than that of Boston, New York, Philadelphia or 
Washington, which have respectively 43.38 inches; 
44.63; 41.17; and 43.50. The distribution of the 
precipitation during the year is as follows: Spring, 9.1 
inches; summer, 3.46 inches; autumn, 14.3 inches; 
winter, 17.9 inches. The autumn and winter are the 
rainy seasons, as is seen, whUe in June, July and 
-•Vugust there are only 3.46 inches. A'ery little snow 
falls, and it quickly disappears. The rains are not 
accompanied by cold winds or thunder storms, and 
there are no blizzards. There are no cold or hot 
waves. There are an average of 79 clear days; 99 
partly cloudy; and 137 cloudy days during the j-ear. 
The greatest number of cloudy days is coincidcntwith 
the seasons of the largest amount of precipitation, 
namely, autumn and winter. 

The water supply comes from Cedar Lake at the 
foot of the Cascade Mountains, a distance of some 
fort}- miles. It is pure and abundant. The sanitary 
development and management of the city is most 
efficient, as evidenced by the low death rate, which in 
1912 was 8.4 per thousand. There are numerous 
parks in and about the city, in all embracing 1,210 
acres. Pt. Defiance Park of 638 acres at the extreme 
point of the Tacoma peninsula, occupies a stately 



94 



REFEREXCE HANDBOOK OF THE MEDICAL SCIENCES 



Tamarlndos 



])osition and has two miles of shore line; it is heavily 
wooded and is traversed by boulevards. Wright 
Park in the center of the city contains a large collec- 
tion of trees, shrubs and flowers. The streets are well 
uaved and there are 125 miles of electric car lines. 
Adjacent to the Tacoma High School is the most 
notable object in the city, the Stadium, with a seating 
capacity of 30,000. It is situated in a natural gulch 
or depression and faces the water. 

The excursions about Tacoma are many and attrac- 
i ive, both by land and water, near and far. There are 
trips on Puget Sound to Seattle, Vancouver, Victoria, 
and other places; and by land to Mt. Tacoma and 
the National Park, which can be reached by train or 
automobile. 

There are also abundant opportunities for hunting 
and fishing. 

Four transcontinental railroads have their terminus 
at Tacoma, and there are various trans-Pacific and 
coastwise steamship lines. 

The harbor is deep and the docks e.xtensive. 

There are excellent schools, numerous churches, 
theatres, and many fine public buildings. 

The market is well supplied, particularly in vege- 
tables, fruits, and many Icinds of fish. 

From all its advantages — natural, climatic, sanitary 
and artificial, Tacoma offers many attractions to the 
prospective resident or tourist. Edward O. Otis. 



Taenia. — A genus of tapeworms. T. saginata, the 
beef tapeworm, and T. solium, the pork tapeworm, are 
the species most often found in man. The latter is 
armed with hooks on the scolex, the former has only 
suckers. Five other species are known. See Cesloda. 

A. S. P 



Tseniidse. — A family of tapeworms. The scolex has 
unarmed suckers, and an armed or unarmed rostellum. 
The vagina is posterior to the cirrus. These parasites 
are mostly found in mammals. The group includes 
several genera which occur in man — Diphylidium, 
Ilymenolepis, Davainea, Taenia, and Echinococcus. See 
Cestoda. A. S. P. 



Tseniinse. — This subfamily of tapeworms includes 
those in wliich the body is of considerable length, and 
the proglottids are longer than broad. The rostellum 
is armed or unarmed. The uterus has a single median 
trunk from which lateral branches develop. The 
genera occurring in man are Twnia and Echinococcus. 
See Cestoda. A. S. P. 



Taeniorhynchus. — A subgenus of the genus Taenia 
which includes T. saffinala, T. africana, T. hominis, 
and T. phiUipina. See Cestoda. A. S. P. 



Tagliacozzi, Qasparo. — Born at Bologna, Italy, 
in 1.54ti. He took the degree of Doctor of Medicine 
from the University of his native city in 1.570. Sub- 
sequently he was appointed Professor, first of Surgery 
and afterward of Anatomv. He died at Bologna on 
Nov. 7, 1599. 

Tagliacozzi devised a plastic operation which, it 
is commonly believed, is known as the Tagliacotian 
operation, a method of rhinoplasty in which the 
flap is taken from the patient's arm. Tagliacozzi's 
most important published writing bears the title: 
"Chirurgia nova de narium, aurium, labiorumque 
defectu per insitionem cutis ex humero, arte hactenus 
omnibus ignota, sarciendo." Frankfort, 1598. 

A. H. B. 



Tait, Robert Lawson. — Bom in Edinburgh 
in 1845, he received his doctor's degree from the 
university of his native city in 1860, and settled in 
Birmingham in 1870. In the following year he was 
appointed one of the two attending surgeons of the 
newlv established Birmingham Hospital for Women. 
He died June 1.3, 1899. 

His more important published writings are the 
following: "Pathologv and Treatment of Diseases of 
the Ovaries," 1873 (4th edition in 1882); "Anatomy 
of the Umbilical Cord," in Proceedings of the Royal 
Society, 1876; "Diseases of Women, a text-book for 
students and practitioners," 2d edition in 1879; 
"Diseases of Women and -Vbdominal Surgery," 1889; 
and "General Summary of Conclusions from 4.000 
Consecutive Cases of Abdominal Section," 1894. 

A. H. B. 



Talcum. — Talc, also called soapstone, French 
chalk, or creta gallica, is a silicate of magnesium, 
HQMgsSiiOia. It is often called a hydrous silicate, 
but as the water is expelled only at a very high degree 
of heat, it may be regarded as basic. In its ordinarj' 
condition it is not used either in medicine or pharmacy 
on account of impurities. In the form of Talcum 
Purificatum, or Purified Talc, it is official in the 
U. S. P. In this form the various aluminum, iron, and 
magnesium salts which were present as impurities 
have been removed. Purified talc is used as a dusting 
powder and to allay irritation and prevent chafing 
from friction. It may be used either alone, or mi.xed 
with starch, boric acid, or zinc oxide; and when per- 
fumed or medicated it is sold as a toilet powder, and 
is often called Talcum Powder. In pharmacy it is 
used as an absorbent and as a filtering agent. 

R. J. E. Scott. 



Tamarindus. — Tamarind, N. F. The preserved 
pulp of the fruit of Tamarindus indica (fam. Legu- 
viinosce). The tamarind is a large, handsome, widely 
spreading, locust-like tree, with rougli, dark-gray bark, 
and rather small, cassia-like, abruptly pinnate leaves. 
The fruit is a flattened, curved, solid "pod," from 
three to six or more inches long; smooth, yellowish- 
brown externally, with a brittle shell, and a firm acid 
pulp surrounding the seeds. The pulp contains a 
skeleton of fibrous bundles running lengthwise over 
the seeds. The tamarind tree grows now in all 
tropical countries, and is, besides, extensively cul- 
tivated. It came originally from the Old World, pre- 
sumably from Africa, but is equally abvmdant in 
India, Australia, and the West Indies. When the 
fruits are ripe, the outer shell becomes brittle and is 
broken between the fingers and removed, the entire 
contents being then packed in kegs and covered with 
boUing syrup. In this way the West Indian tama- 
rinds, which comprise most of those that reach our 
market, are prepared. In the East, sugar is oft*n 
used instead of syrup, or they may be packed dry, 
without any sweetening, in a hard, semisolid mass. 

Preserved tamarinds, as they reach us, are in a 
moist, reddish-brown, pulpy, stringy mass, with 
numerous flattish-quadrangular, smooth seeds, and a 
little thick, dark sjTup. They have a pleasantly 
sweet and acid taste. Mixed with water, they make a 
pleasant acid drink, which was formerly used in 
fevers and other forms of sickness. They are much 
less employed at present. 

Composition. — Citric acid, eight or nine per cent, is 
the important constituent. .About one and one-half 
per cent, of tartaric acid, a little malic acid, and, say, 
three per cent, of potassium bitartrate, are adjuvants 
to the former, and add to the acidity of the fruit. 
Gum, jelly, and ordinary vegetable matters, and, in 
our preserved tamarinds, the sugar that is added, 
complete the list of constituents. 

95 



Tamarlndns 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



Uses. — Tamarinds are rather an agreeable luxury 
than a medk-iue and in some eountries are consumed 
extensively as a preserve. They possess some slight 
laxative properties, like prunes, barberries, figs, and 
other acid and sugary fruits. Here they are used to 
make a refreshing acid drink or !is an adjuvant to 
some laxative compound. The Confection of Senna 
(Confcclio Seiiua, formerly official) contains ten per 
cent, of them. The dose of tamarinds is indefinite. 

W. P. B0LI.ES. 



Tampa. — This winter health resort is situated 
about midway of the peninsula of Florida, on the 
Gulf side, at "the head of Tampa Bay. It is about 
twenty-five miles di-stant from the coast, in Lat. 
27° 57' N., and has a permanent population of 
38,527. It is one of the important commercial cities 
of Florida, and has extensive manufacturing interests, 
principally in cigars, employing large numbers of 
Cubans. There are various churches, an opera- 
house, street cars, electric lighting and water works, 
sewers, and clean, paved streets. Port Tampa, where 
the largest steamers land, is nine miles from the city, 
with which it is connected by rail, and from here 
steamers leave for Havana, Key West, and various 
Gulf ports. 

On the opposite bank of the Hillsborough River, 
at the mouth of which Tampa is located, is the Tampa 
Bay Hotel, situated in a beautiful park of 150 acres, 
with a botanical garden containing a great variety of 
native and imported trees and plants. This hotel is 
one of the most imposing and extensive in Florida — the 
land of extravagant buildings of this sort. It is of 
Moorish architecture and contains nearly .500 rooms, 
and is most luxuriously equipped. Connected with it 
is a casino, with a swimming pool, and an exposition 
building. There are several other hotels in the city 
proper, and one at Port Tampa. There are many 
opportunities for fishing, hunting, boating, and driving, 
and a variety of excursions about the beautiful bay. 
The surrounding country is sandy, but nevertheless 
supports a luxuriant tropical vegetation, groves of 
orange, lemon, and pine trees abounding. 



Climate of Tampa, Florida. L 



27°57'N.;LoNGiTui; 



Temperature — De- 
grees Fahr, 
Average or normal 
Mean of warmest. 
Mean of coldest.... 
Averagedaily range 
Highest or m 



Lowest 



Humidity- 
Average relative. 
Precipitation — 

Average in inches 
Wind- 
Prevailing direc- 
tion 

.\verage hourly ve- 
locity in miles. . 
Weather- 
Average number 

clear days 

Average number 

fair days 

.\verage nuniber 
clear and fair 
days 



G2.2° 
71.2 
.5.3.2 
18.9 

81.3 



83.4% 
1.57 



12.1 



58.0° 
67.8 
48.0 



78. 1 
32.7 

81.6% 
2.45 



. ,-) 



12.3 10.4 

I 

24.4 '25.0 



03, 1« 
71.7 
34.6 
17.1 



35.7 

83.8^ 
2.81 
N. E. 
0.9 

8.4 
14.3 



84.2 
39.7 



U.7 
14.4 



94.4 
28. 1 

81.2% 
53.09 

N. E. 

6.1 

115.0 



The climate is a warm, equable, moist one, the 1 



annual temperature being nearly that of Cairo, 
Egypt. Both in climate and vegetation Tampa 
partakes of the characteristics of southern tropical 
Florida. On account of the humidity and enervat- 
ing quality of the climate, such a resort as Tampa is 
not favorable for tuberculosis; but it is useful for a 
variety of cases needing a mild, equable, sunny, 
winter climate, as has been indicated in the article 
upon Florida in Vol. IV. of the Handbook. 

The accompanying chart gives the various climatic 
data for the four winter months and also for July. 
The characteristic features are seen to be mildness 
and equability of temperature, a high humidity, 
much sunshine, and a comparatively high annual 
rainfall, the larger part falling during the summer, 
features common to all the coast resorts of the Florida 
peninsula. 

Tampa is readily reached by rail direct, or one can 
make a portion of the journey by water. 

Edward O. Otis. 



Tanacetum, Tansy. — The dried leaves and top of 
Tanacelum vulgare L. (fam. Composilm). Tansy is a 
perennial herb, native of Europe and Southern Asia. 
It was introduced into the United States as a culti- 
vated aromatic and has become abundantly natural- 
ized as a weed along roadsides and in waste places. 
The stems are somewhat tufted, erect, nearly simple, a 
foot or two, rarely a yard, high; leaves shortly and 
stoutly petioled, rarely exceeding 20 centimeters (8 
inches) long and 10 centimeters (4 inches) broad, 
obovate when flattened, pinnate, the pinnae about ten 
or twelve pairs, linear-oblong, obtusish, pinnatifirl, their 
segments oblong, acute, incisely serrate or lobed; thin, 
with a strong midrib, smooth, dark green, finely 
depressed-glandular; flower heads in a small, loose, 
terminal corymb, long-peduncled, yellow, nearly I 
centimeter (about -| inch) broad, having an imbricated, 
saucer-shaped involucre, a convex, naked receptacle, 
and numerous yellow tubular florets, which are perfect, 
or the outer circle pistillate; highly and peculiarly 
aromatic, the taste pungent and very bitter. 

It contains the peculiar bitter substance tanacelin, 
which is amorphous, very hygroscopic, and soluble in 
both alcohol and water. This imparts the most of the 
bitter taste, although the volatile oil is also bitter. The 
latter exists to the extent of about one-fourth of one 
per cent., has a specific gravity of about 0.955, and is 
of a yellowish-green color, becoming more or less 
brown upon exposure. It is soluble in about three 
parts of seventy-per-cent. alcohol. It is highly aro- 
matic, bitter, and pungent, its important constitu- 
ent being Ihujone (tanacetone). Tansy also contains 
some tannin, malic acid, and other unimportant 
constituents. 

Besides the properties of tansy as one of the more 
powerful aromatic bitters, together with the diapho- 
retic and diuretic properties of its class, it and its 
oil have been used from time immemorial as anthel- 
mintics. Oil of tansy, and tansy itself in large doses, 
are poisonous, the general symptoms being similar to 
those of the coniferous oils (juniper, turpentine, savin, 
etc.). These symptoms are: great; irritation, vomit- 
ing, abdominal pain, painful diuresis, convulsions, 
coma, and death. They belong to the more painful 
class of poisons. They are also powerfully enmiena- 
gogue, though the symptoms are painful and the use 
of the drug for this purpose is not desirable. They are 
liable to cause abortion, though they usually fail of 
this purpose when taken with such intent, as is com- 
monly done. 

The dose of tansy in the form of the fluid extract 
is nixv-oi (1.0-4.0), though this represents the 
extreme dose which should be used. The oil may be 
administered in doses of lUi-v (0.06-0.3). So little 
as a fluidram of the oil has proved fatal. 

Henry H. Rusbt. 



96 



REFERENCE HAXDBOOK OF THE MEDICAL SCIEN'CES 



Tannal, basic aluminum tannate, A]2(OH)4.- 
(Ci4H90s)2 + 10H2O, is a brownish yellow powder 
formed by precipitating an aluminum salt with tannic 
acid in the presence of an alkaH. It is employed as an 
astringent dusting powder for wounds and ulcers, 
and as an insufflation in catarrhal conditions of the 
nose and throat. It is insoluble in water, but its 
combination with tartaric acid dissolves readily and 
is known as "soluble tannal." The solution, how- 
ever, slowly decomposes. W. A. Bastedo. 
R. J. E. Scott. 



Tannalbin is a tasteless, odorless, light-bro^Ti pow- 
der made by drying tannin albuminate at 1 10°-120° C. 
It is light and bulky and contains about fifty per cent, 
of tannic acid. It is insoluble in water or the gastric 
juice, but slowly dissolves in alkaline media, as in the 
intestine. Though tannalbin has very little astrin- 
gency. the weight of evidence indicates that it is as 
efficient in diarrheal conditions as any of the astrin- 
gent drugs. Most authors claim that it does not act 
at all in the stomach, but that it sets free its tannic 
acid in the intestines. It is administered in capsule 
or in mixture, or in combination with small doses of 
calomel, or mixed with starch water as an enema. The 
dose for an adult is about 10 grains (0.7 gram) several 
times a dav. W. A. B-v'^tedo. 

R. J. E. Scott. 



Tannic Acid. — {Aciiium Tannicum, U. S., Br., Ger. 

Gitllolanxic Acid. Digallic Acid. Tannin. HCu- 
HsC = 321.22). A tannin obtained from nutgall. .\ 
light-yellowish amorphous powder, usually cohering 
in the form of glistening scales or spongy masses, odor- 
less, or having a faint, characteristic odor and a 
,-trongly a.stringent taste; gradually turning darker 
when exposed to air and light. 

Tannic acid is freelj- soluble in both alcohol and 
water, as well as in glycerin. The characteristic blue- 
black color produced in a solution of tannic acid when 
a ferric salt is added forms the basis of tests for its 
presence. The form of tannic acid here considered is 
characterized by its convertibilitj- into gallic acid, of 
which it is the anhydride. Although generally stated 
tliat it occurs in some other varieties of gall and in 
several other vegetable substances, certain differences 
are perceptible in these, and it has been cjuestioned 
whether any of them can be considered as identical 
with the one under consideration. It may be extracted 
from the powdered galls by several processes. The 
most convenient method is to exhaust the latter with 
warm water and then thoroughly remove the im- 
purities by churning with ether. The most common 
impurity present is resin, though after a time more or 
less gallic acid is likely to be formed, if carelessly 
preserved, the properties thus becoming weakened. 
Tannic acid is associated in the plant with more or less 
glucose, a part of it apparently combined as a gluco- 
>ide, and this glucose often exists as an impurity of 
tannic acid. 

Incompatibility. — The wide distribution of tannic 
acid, or its associates in the group, among vegetable 
'Irugs, lends great importance to its numerous in- 
ripmpatibilities, the more important ones being liere 
stated. Tannin is slowly destroyed by remaining 
in aqueous solution, the process hastened by heat. 
Alkaloidal .salts in aqueous or weak alcoholic solu- 
tion are decomposed by tannin, their tannates, which 
arc but slightly soluble in water, being precipitated. 
I It her organic substances whose solutions are pre- 
cipitated by tannic acid are albumin, gelatin, gluten, 
starch hydrate, and many glucosides and amaroids. 
A solution of antipyrin is also precipitated and iodo- 
iMrm is decomposed. Tannin in a solution of iodine 
prevents the latter from turning starch blue. Tannic 
acid is incompatible with ferrous salts, giving a 

Vol. VIII.— 7 



gelatinous precipitate, and with ferric -salts, giving 
a black color to a weak solution (its physiological 
action being not thus destroyed;, and a black pre- 
cipitate with a strong one, the strength correspond- 
ingly weakened. Solutions of salts of lead, copper, 
silver, chromium, mercury, bismuth, antimony, 
and most other metals yield tannates as precipitates, 
and nitric acid converts it into oxalic acid. \Aith 
sulphuric, nitric, and hydrochloric acid, precipitates 
are yielded. Hydriodic acid is formed when tannin is 
added to iodine with water. Oxidizing agents are 
reduced by tannin. The stronger of them, like potas- 
sium chlorate, may produce explosions when tritu- 
rated with tannic acid. With spirit of nitrous 
ether or amyl nitrite, a gas is yielded. Chlorine, 
iodine, and bromine are incompatible. Lime-water 
and tarinin yield a precipitate, as do potassium and 
ammonia and their carbonates. 

The physiological actions and uses of tannic acid 
depend almost wholly upon its chemical property of 
coagulating albumin in the form of a tannate, and 
this is especially true of its local action. In this way, 
the following effects are produced: A protective film 
is formed upon raw surfaces; bleeding orifices, if 
small, are closed by blood clots in their mouths and 
by a contracting clot about them; relaxed muscular 
tissue is contracted, thus increasing the hemostatic 
effect; it coagulates the saliva and buccal mucus, and 
it is probably due to its mechanical action that the 
taste and general sen.sation of the mouth are dimin- 
i.shed; in the .same way it blunts the appetite and checks 
digestive activity, but arrests gastric and intestinal 
hemorrhage, as well as intestinal discharges, thelalter 
effect not to be confounded with that of a stinudation 
of the vasomotor nerves by volatile oils and other 
stimulants. Here again the mechanical blunting 
of the nerve endings results in a decrease of the peri- 
staltic action, tannic acid being thus one of our most 
important constipating agencies. Here its local 
action may be said to end, while its systemic action 
becomes that of gallic acid, to which the reader is 
referred. It may be mentioned, however, that tannic 
acid has a distinct irritating tendency, which becomes 
apparent when overdoses are taken. In this way it 
may act as an emetic or even as a purgative. 

The uses of tannic acid thus fall naturally into two 
classes, one of which is to be found discussed under 
gallic acid. Its chief local uses are to protect and 
stimulate the healing processes in all simple ulcers 
and in skin diseases which exhibit a superficial 
inflammatory tendency. Mild hemorrhages of the 
skin or of the nares, mouth, stomach, or intestines 
may be promptly arrested by it. the dry powder 
being best where direct application is possible. 
Excessive and malodorous local perspirations are 
cheeked, as weU as foul exudations from the mucous 
membranes of nose, throat, and uterus. .\t the same 
time, an overrelaxed condition of these membranes, 
as well as of the rectum when hemorrhoids are present, 
is promptly corrected, although the effect is likely 
to be but temporary, .\cute inflammatory condi- 
tions of the fauces, and to a less extent of the stomach, 
are often promptly relieved. Inhalation of a spray 
of tannic-acid solution will check many cases of hxmop- 
tysis, and this method, when possible, is much more 
efficient than its internal administration. The ordi- 
nary dose is gr. i-v (0.0(>-0.3), but this is often 
largely increased in order to check hemorrhage. 
The official preparations are the styptic collodion, 
the glycerite, and the ointment, each of twenty-per- 
cent, .strength, and the troches, each containing about 
one grain. A five-per-cent. or ten-per-cent. aqueous 
solution is often used for irrigating the nares or the 
vagina. Hexry H. UrsBT. 



Tannigen, diacetyl tannin, CuH,(CHiC0)20,, is a 
yellowish-gray, odorless, and tasteless powder, pre- 



97 



TaniilK^n 



pared by the action of acetic anhydride or acetyl 
chloride "on tannic acid dissolved in glacial acetic acid. 
It dissolves in dilute solution of sodium borate or 
phosphate and in alcohol, is slightly soluble in ether, 
and IS insoluble in water, though it tends to absorb 
moisture from the air. It is decomposed by alkalies, 
and is colored blue-black by ferric salts. Passmg 
unchanged through the stomach, it is broken up in the 
intestine, where the slow liberation of tannic acid gives 
a mild and continuous astringent effect. In diarrhea, 
dysentery, and especially the summer diarrheas of 
children, it has been found superior to the prepara- 
tions of krameria, catechu, hematoxylon, and other 
vegetable astringents. It has recently been used for 
the diarrhea of pellagra. The dose is IJ grains (0.1 
gram) several times a day for young children, and 5 
to 10 grains (0.35-0.7 gram) for adults. 

Tannigen has also been employed as an insufflation 
in nose and throat affections. W. A. Bastedo. 
R. J. E. Scott. 



Tannoform, methylene ditannate, CIl2(CuH909)2, 
is a condensation product obtained by adding a solu- 
tion of formaldehyde to a solution of gallotannic acid 
in hot water and precipitating with hydrochloric acid. 
It is a loose pinkish-white powder, insoluble in water 
or acids and soluble in alcohol; it dissolves in alkalies 
with decomposition. 

In the intestine tannoform sets free tannic acid and 
formaldehyde, and has been so used as an intestinal 
astringent" and antiseptic. But it is not very widely 
employed thus, because of the possible irritation of the 
formaldehyde. It is a clean, dry antiseptic and deo- 
dorizing powder, and is used either pure or diluted 
with starch or talcum. In wounds, ulcers, and bed- 
sores it seems to have marked healing properties, in 
hyperidrosis and bromidrosis it is siccative and deo- 
dorizing, and in moist eczema, pruritus, intertrigo, 
and burns it forms a serviceable dusting-powder. 
In chronic catarrh of the nasal passages, especially in 
ozena, it is used as an insufflation. 

Similar compounds prepared from formaldehyde 
and the tannins of aspidosperraa, oak bark, and cin- 
chona are called respectively quebrachinoform, querci- 
form, and quinoform. 

The bismuth salt of tannoform is "bismal." 

W. A. Bastedo. 
R. J. E. Scott. 



Tannopin orTannon, (CH2)6N4.3Ci4Hio09, is a con- 
densation product of tannic acid and hexamethylene- 
tetramine (urotropin). It contains eighty-seven per 
cent, of tannic acid and is a brown, odorless and taste- 
less, slightly hygroscopic powder, which is insoluble in 
water, alcohol, ether, or weak acids, but dissolves, 
probably undergoing change, in weak alkalies. It is 
said to liberate tannic acid and formaldehyde in the 
intestine, and for this reason is employed as an intes- 
tinal antiseptic and a.stringent. Schreiber, Meier, 
and Tittel have reported highly satisfactory results in 
tuberculous enteritis, and in acute, subacute, and 
chronic diarrheas. The dose is 3 to 15 grains (0.2- 
1.0 gram) several times a day. W. A. Bastedo. 

R. J. E. Scott. 



Tarantula. — A name which has been applied to 
large spiders in various parts of the world. In 
southern Europe the large Lycosida; or wolf-spiders, 
are greatly feared. In the warm regions in America 
the Avicularoidea are usually called "tarantulas." 
Though somewhat poisonous, they are less deadly than 
the spiders belonging to the genus Lalrodecles which 
are also found mostly in tropical countries. See 
Insects, Poisonous. A. S. P. 

98 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCIC 



Tarasp-Schuls. — This health station and spa is 
situated in the Lower Engadine Valley, thirty-four 
miles from Samaden, with which it connects by 
diligence several times daily. It consists of the three 
places, all near together, Tarasp-Schuls, Schuls, and 
Vulpura. Schuls, 3,970 feet above sea-level, is the 
largest village in the Engadine, next after St. Morits 
and contains about 1,100 inhabitants. It is pic- 
turesquely situated on a slope of the valley, with the 
Inn below and, opposite, a stately range of well- 
wooded mountains, and is divided into an upper and 
a lower town, in the former of which most of the h tels 
and pensions are situated. On the high-road separat- 
ing the two portions of the town is situated the bath- 
ing establishment, with eighteen bath- and two 
douche-rooms for iron and fresh-water baths. 

Vulpura is a suburb consisting of large and well- 
appointed hotels, lying on the opposite side of the 
river from Schuls, and about 200 feet above it, on a 
thickly wooded height. It is at a distance of twenty 
minutes from the Kurhaus Tarasp, by a good road. 

On the high road about a mile to the west of Schuls 
are the baths of Tarasp, consisting of an extensive 
Kurhaus with a "pump-room" and baths, and sur- 
rounded with pleasant gardens and parks. The whole 
country about is most attractive, and affords innumer- 
able opportunities for walks and excursions in every 
direction, amidst grand scenery and in a pure moun- 
tain atmosphere. One who desires to take a course 
of these waters can conveniently reside at any of the 
three localities. 

The climate of this region is somewhat milder than 
that of the Upper Engadine, although it partakes of 
the same general characteristics, viz., a rarefied 
atmosphere, moderate temperature, dry air and free 
from dust, protection from high winds, and increased 
intensity of the sunlight and heat. The mean tem- 
perature during the season (June 1 to September 
15) is 57.14° F.; the maximum, 87.08° F.; and the 
minimum, 33.8° F. The mean relative humidity is 
from 65 to 76 per cent., and there is an average rainfall 
of 9.40 inches. There are on an average during the 
season 39 perfectly clear days, 27 fair ones, 34 rnore 
or less overcast, only 6 or 8 of which are actually rainy. 

The effect of the climate is stimulating and tonic, 
and may be rather severe for delicate persons, as 
sudden changes occur. For one, however, fairly 
robust and who desires to unite the high mountain 
air cure with a course of the waters and baths offered 
here, hardly a more admirable and charming resort 
could be found. "Scarcely another station in Europe," 
says Linn, "unites so many important qualities." 

There are eight cold mineral springs that are used 
at this resort, although there are many more in the 
neighborhood. Four of the springs used yield sul- 
pliated alkaline waters of the class known as the 
"Cold Glauber's Salt Springs," similar to those at 
Carlsbad. The Lucius and Emerita Springs of this 
class are used for drinking and bathing; and the 
Ursus and Neue Bade Quelle are only used for bath- 
ing. The rest of the springs are iron, yielding a 
gaseous chalybeate water known as "Sauerwasser." 
Of these the Bonifacius is used for drinking alone; 
the Wy for drinking and bathing; while the Carola 
is used for bathing alone. The four sj^rings of Sotsass 
are used as a favorite table water. Compared with 
the waters of Carlsbad, Marienbad, Kissingen and 
Vichy, the Lucius Spring at Tarasp contains about the 
same amount of sulphate of soda as Carlsbad, but 
nearly or quite three times as much carbonate of soda 
and chloride of sodium, and at least three times as 
much carbonic acid. The carbonate of soda is slightly 
in excess of that found in the water of Vichy, and the 
chloride of sodium is about a fourtih less than at 
Kissingen. Marienbad contains more sulphate of 
soda, but less of the other ingredients. 

The analysis of the Luciusquelle by Husemann is as 
follows: 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



Tartaric Arid 



In Sixteen Ounces of the Water there Were: 
Grains. 

Sulphate of Boda 16. 131 

Sulphate of potash 2.916 

Borate of soda 1 . 312 

Nitrate of soda . 006 

Chloride of sodium 28 . 216 

Chloride of lithium 0.022 

Bromide of sodium . 173 

Iodide of sodium . 007 

Bicarbonate of soda 37 . 426 

Bicarbonate of ammonium . 507 

Bicarbonate of lime 18.800 

Bicarbonate of strontium 0.005 

Bicarbonate of magnesia 7 . 524 

Bicarbonate of ferric oxide 0.165 

Total amount of fixed solids 113.210 

True free carbonic acid 33 .92 cu. in. 

Of the Chalj'beate Springs the Bonifacius is the 
strongest, containing 0.045 per thousand parts of the 
bicarbonate of iron. The iron baths are heated by 
a tube througli which steam passes, so as to cause 
comparatively little of the carbonic acid to escape. 

Three hours distant from Schuls are the acidulous 
mineral springs of Val Sinestra, containing a little 
arsenic. These waters are brought daily to Schuls. 

As to the therapeutics of these waters, the four soda 
acidulous springs are more or less successfully em- 
ployed in many different functional and organic dis- 
eases and conditions, such as olsesity, chronic consti- 
pation, hemorrhoids, dyspeptic conditions, gall-stones, 
glycosuria of fat persons, affections of the kidneys and 
bladder, diabetes, gout. By warming the water 
before drinlcing, it can be made to resemble more 
closely Carlsbad water. 

The Chalybeate Springs are used in anemia and 
debilitated conditions. In combination with the 
hydrotherapeutic processes massage is given, and the 
diet is carefully regulated. Good physicians who 
speak English are found at this spa. 

Most visitors taking the waters usually frequent the 
pump-room at the Kurhaus Tarasp at an early hour 
in the morning, at which time there is music. There 
is a very delightful path along the river from Schuls 
to Tarasp, a walk over this occupying about half an 
hour; and the hotel-keepers at Schuls provide (gratis) 
conveyances which run at frequent intervals during 
the day between these two places. It is well to be pro- 
vided with warm clothing, for the weather is frequently 
cool. 

There are several ways of reaching Schuls: by rail 
to Saraaden and thence by diligence or carriage; or, by 
rail to Landeck, and thence by diligence in eight hours. 
Coming from the south, one can go by rail to Chia- 
venna, and thence by diligence over the Maloja Pass 
and through the Upper Engadine, a long ride, but 
through grand and delightful scenery; by this route 
it is well to break the journey at Samaden. 

Edward O. Otis. 



Taraxacum. — Dandelion. — "The dried rhizome 
and root of Taraxacum officinale Weber (fam. Cum- 
positce)" (U. S. P.). This well-known plant grows in 
the greatest profusion throughout most of tlie north 
temperate zone and is being increasingly cultivated as 
a food plant. Its reputation as a drug is of the most 
ancient character, but its professional use has steadily 
declined in the face of more accurate knowledge of drug 
action. The plant has no true rhizome, as is indicated 
in the official definition. The root is vertical, but rather 
crooked, mostly simple or with one or two branches 
parallel with and close to the parent, rarely reaching a 
foot in length and having the thickness of the finger. 
The drug more commonlj- has the dimensions of a lead 
pencil; it is brown, deeply wrinkled, light, soft, and 
brittle. On fracture, the wood zone is seen to be 
small and bright yellow, the bark whitish if carefully 



dried, otherwise dark. It contains numerous circles 
of laticiferous ducts, which, on paring the ends, 
glisten slightly, if the drug is of fine qualit v. The taste 
is distinctly bitter, and slightly sweetish, and a gummy 
consistence is appreciated upon chewing. The ac- 
tivity resides in the milky juice which fills these 
ducts. 

Composition. — The small amount of sugar, gum, 
resin, and wax-like substances, and the large amount 
of inulin are scarcely medicinal. The bitter principle 
is taraxacin. .\n alkaloid exists in minute amount. 

Dandelion exerts no marked physiological action. 
It is somewhat laxative, hence depurative, and, be- 
cause of a shghtly increased elimination of bile, has 
been supposed to be a hepatic tonic. It does seem to 
possess slight alterative and tonic powers. 

The dose of the fluid extract is fl. 3 i-ij (4.0-8.0), 
of the extract gr. viij-x.xx (0.5-2.0). 

Henry H. Rcsby. 



Tardieu, Ambroise Auguste. — Born at Paris, 
France, on March 10, 1S18. In 1.S43 he received the 
degree of Doctor of Medicine from the University of 
Paris, and already in the following year he was niade 
an .Agreg(5 by the same institution. In IS.5.3 he took 
part in the competition for the Chair of Hygiene; 
and, although he did not win the coveted position, 
which was awarded to Bouchardat, he wrote for this 
occasion a thesis on "Voiries et Cimetieres," which was 
afterward published and was con.sidered for many 
years the best and most complete treatise on the sub- 
ject. In 1861, after the death of .\delon, who had up 
to that time held the chair, he was chosen full Profes- 
sor of Medical Jurisprudence; and in 1864 he succeeded 
Rayer as Dean of the Faculty of Medicine. During 
a large part of his career he was one of the .\ttending 
Physicians at Hotel-Dieu. He died Jan., 12, 1879. 

Tardieu, during a period of many years, was held 
in the highest esteem in France as a medicolegal ex- 
pert, and published a number of valuable treatises 
on medicolegal topics. The majoritj' of these may be 
found in the Annates d'hijgihne publique et de medecine 
legale. A. H. B. 



Tarsonemidae. — A family including minute mites 
which show a striking sexual dimorphism. A number 
of species are true parasites on insects, others attack 
plants, and several may be accidental parasites on 
man. Pediculoides vetdricosus often causes a painful 
eruption on the skin. See Arachnida. A. S. P. 



Tartaric Acid (II2C4H4O6). — A dibasic organic 
acid obtained from wine lees or argol, and contain- 
ing not less than 99.5 per cent, of C4H6O6. Color- 
less, translucent, monoclinic prisms, or crystalline 
crusts, or a white powder, odorless, having a purely 
acid taste and permanent in the air. 

Tartaric acid is soluble in both alcohol and water, 
very freely in the latter. It forms during the process 
of fermentation of wine, in the form of the bitartrate 
or acid tartrate, which is scraped from the insides of 
the casks in a mass called argols or tartar, or, after 
purification, cream of tartar. This is converted into 
calcium tartrate by the action of calcium carbonate 
in the form of powdered chalk. The calcium is then 
removed b}' sulphuric acid, setting free the tartaric 
acid, which must be carefully freed from traces of 
potassium, calcium, and sulphuric acid. 

Tartaric acid hiis no special medicinal properties 
as distinguished from those of its class. It is one of 
the mild acids recommended for use in alkali poison- 
ing, and it is useful (in the form of olTervescent 
powder or Seidlitz powder) for freeing carbonic acid 
in the production of carbonated liquors. It is also 

99 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



much used sxs a fraudulent substitute for citric acid 
in tlie production of citrate-of-potassium solution. 
IlEN-nv H. llrsDY. 



Taste. — 1. Definition and Introduction. — Taste 
is a special sense. A special sense is one provided wit h 
specialized end organs and located in structures that .-ire 
esi)cciallv adapted to serve the organism in receiving 
and conduct iiiK the stimuli from the sensory end 
organs to the sensorium in the brain. 

The sense of taste ijosse.sses as specialized end organs 
the gustatorv or taste buds, located on the surface of 
the tongue, the fauces, the soft palate, and the epiglot- 
tis. That the taste buds are the sole organs of taste 
is far less certain than it is that the eye is the sole end 
organ of vision. It is true that tho.se portions of the 
oral mucous membrane which possess the sense of 
taste are the only places where the taste buds are 
found. On the other hand, there arc many other 
nerve fibers which possess filaments and other endings 
in this same region. The other nerve endings in this 
region are similar to those found in other parts of tlie 
body, and serve in those parts the tactile and tempera- 
ture senses. The tongue possesses the tactile and 
temperature senses to a high degree. Although our 
conclusion that the gustatory buds are the sole end 
organs of taste is reached by a course of inductive 
reasoning, we may feel secure that our conclusion is a 
tenable one. 

2. Anatomical Considerations. — ^The ta.ste bud is 
an epithelial structure composed of spindle-shaped 
cells grouped in a spheroidal mass with one pole at the 
surface of the epithelium. The cells may be classified 
in two orders, the sustentacular and neuroepithelial. 
The sustentacular cells when located on the surface of 
this spheroid are called tegmental cells, and are some- 
what larger than those which make up the internal 
part, of the bud. Lying between the sustentacular 
cells in the midst of the bud are the delicate, spindle- 
shaped, neuroepithelial cells, whose nuclei are in the 
basal portion farthest removed from the epithelial 
surface and whose external ends terminate in delicate 
hair-like filaments. Surrounding the nuclear end of 
the neuroepithelial cells is a copius arborization of the 
delicate terminal fibrils of the telodendria of the 
gustatory neurones. These arborizations may also 
be found in some cases to surround the inner ends of 
the sustentacular cells. The taste bud possesses at 
the epithelial surface a minute pore, through which 
.substances in solution may pass into the taste bud 
and will be drawn by capillary attraction into the 
innermost spaces between the sustentacular cells and 
neuroepithelium, and thus be brought into immediate 
contact with the gustatory nerve endings. 
_ Those gustatory nerve fibers which leave the poste- 
rior third of the tongue, the f ossa;, palate, and epiglottis, 
pass to the gustatory center by way of the glosso- 
pharyngeal nerve. Those which leave the anterior 
two-thirds of the tongue pa.ss at first into the lingual 
branch of the inferior maxillary division of the fifth 
nerve. They leave the lingual branch and pass by 
way of the chorda tympani back to the seventh nerve. 
From here to the gustatory center their course has not 
been definitely traced. The clinical evidence seems to 
favor the view that they pass by way of the seventh 
nerve into the base of the brain, while experimental 
evidence as well as observations on the embryonic 
development of the cranial nerves indicates that the 
fibers leave the seventh nerve at the geniculate 
ganglion and pass by way of the Vidian nerve and 
Meckel's ganglion back to the fifth. Leaving the 
detailed course of the lingual gustatorv nerves to be 
determined by further experiment, "we may rest 
assured that eventually thev make their way "to the 
same gustatory center to which the glossoph'ar\Tjgeal 
fibers may be traced. 

100 



3. PuysioLOGY OF THE Sense OF Taste. — Many of 
the perceptions attributed to taste really depend quite 
as mucli upon smell as upon taste. We usually apply 
the term fltiror to those sensations which depend upon 
both .smell and taste; e.g. one speaks of the flavor of 
roast beef or of coffee. The fact that closure of the 
nose impairs the flavor of the beef or coffee indicates 
that a part of the flavor is to be attributed to the sense 
of smell. The sense of taste alone seems to be confined 
to sensations arising from four distinct stimuli: (1) 
sweet, (2) bilter, (3) arid, (4) sail. All purely taste 
sensations are either modifications of or combinations 
of these four fundamental sensations. The sense of 
taste is excited usually by those substances which pass 
into solution — i.e. insoluble substances are tasteless. 
It may be noted in passing that mechanical stimuli 
applied to the gustatory surface are capable of arous- 
ing sensations of taste, and the same is true of electrical 
stimuli. In the case of the latter, the fact that the 
cathode usually tastes bitter-alkaline, while the anode 
usually tastes acid, would seem to show that the 
efficient stimuli are the basic ions which gather at the 
cathode and the acid ions which gather at the anode 
respectively. Though this is undoubtedly the way to 
account for the taste of the cathode and anode in the 
constant current, it does not throw light upon the fact 
that taste sensations are also aroused by induction 
shocks. 

The sensation will vary in strength with: (1) the size 
of the area stimulated, the sensation being more in- 
tense the greater the area stimulated; (2) the concen- 
tration of the solution, being more intense the stronger 
the solution; (3) the temperature of the solution, being 
more intense the nearer the temperature is to that of 
the blood; (4) the mechanical friction of the tongue 
against the palate, being stronger with moderate 
friction than without it. 

The sense of taste varies in acuteness (1) through 
certain hereditarj' influences, and (2) through cultiva- 
tion. A good example of marked acuteness of taste 
acquired by cultivation may be found in professional 
tea-tasters and wine-tasters. 

1. To Delermine the Acuteness of Taste. — Make four 
standard solutions, as follows: (1) Sugar, one gram of 
dry saccharose in 100 c.c. of distilled water. (2) 
Quinine sulphate, one centigram in 1,000 c.c. of dis- 
tilled water. (3) Acetic arid, one gram of glacial acetic 
acid in 1,000 c.c. of distilled water. (4)5a/(, one gram 
of dry sodium chloride in 100 c.c. of distilled water. 

In the use of these solutions prepare the gustatory 
surfaces by thoroughly rinsing the mouth with distilled 
water or with boiled water. Take a uniform ciuantity 
of the solution into the mouth at each observation. 
A convenient quantity is 4 c.c. or a common teaspoon- 
ful. Rinse the mouth before each new observation. 

The following table gives results obtained by a num- 
ber of observers. The numbers indicate the number 
of parts of water to one of the substance to be tasted, 
to produce the weakest solution w^hich the individual 
tested could positively and unerringly recognize. 



Mr. 


Sugar. 


Quinine. 


.\eetic acid. 


Salt. 


A 


700 
600 


1,000,000 
500,000 
230.000 
400,000 


7,000 
8,000 
4,400 
3,000 
4,000 
6,000 
6,000 
4,500 
6,000 
7,500 

1 to 5,640 


425 
500 


B 


C 


D 


300 
700 
400 
333 
500 
500 
650 

1 to 520 


700 


E 


F 


400,000 
400,000 
400.000 
450,000 
200,000 

1 to 444,000 


600 


G 


H 


4 SO 
325 
325 

1 to 469 


I 


J 


Average 



Besides the results here recorded, numerous data 
were furnished by other observers. 



REFERENCE HANDBOOK OF THE MEDIC.U. SCIENCES 



Tate SprlDK 



This table and the supplementary data justify the 
following conclusions: 

1. The acuteness of taste for sugar varies from 1 
jjart of pure cane sugar in 300 parts of water to 1 in 708, 
with an average of 1 in 520. 

2. The acuteness of taste for salt varies from 1 in 
:'.25 to 1 in 700, with an average of 1 in 469. 

3. The acuteness of taste for acetic acid varies from 
1 in 3,000 to 1 in 8,000, or an average of 1 in 5,040. 

4. The acuteness of taste for sulphate of quinine 
varies from 1 in 200,000 to 1 in 1,000,000 with an 
average of 1 in 444,000. 

From these results it is evident : 

5. That there is considerable individual variation. 

6. That the taste is most acute for the less common 
stimuli of bitter and acid than for the more common 
stimuli of salt and sweet. 

7. Several subjects recorded a marked decrease in 
the acutene.ss after the use of tobacco. 

8. One subject recorded a noticeable increase in the 
stimulation when the solutions w-ere warmed from 20° 
to 40°C. 

9. One observer found that the tip and edge of the 
ti )ngue were more acute than other parts of the tongue 
in detecting slight differences in the strength of the 
solutions. 

10. One observer, reporting a series of very careful 
experiments upon four individuals, three of whom are 
members of the same family and accustomed to the 
free use of salt and vinegar in their regular diet, con- 
cluded that the fourth individual, not accustomed to 
the free use of salt and vinegar, has a greater sensitive- 
ness for saline and sour substances than have the three 
individuals who are so accustomed. 

As to the interval of time between the application of 
the stimuli and the taste perception, the obser\-ations 
seem to justify the following conclusions: 

11. The interval between stimulation and sensation 
(latent interval) varies inversely as the number of 




Fia. 4720. — Localiiation of Taste. Bitter, ; acid ; salt, 

— . — . — ; sweet ; T. Tonsils; F.C., Foramen cecum; C F., 

Circumvallatc papillffi; F.P., Fungiform papilla;. (Hall: " Text- 
hnok of Physiology." Lea Bros., Philadelphia.) 

I^apillfe per unit area in the portion of the gustatory 
apparatus stimulated. 

12. The interval between stimulation and sensation 
varies directly as the blood supply of the part at the 
lime of stimulation. 

II. To Determine Localization of the Sense of Taste, i.e. 
to find whether there are areas of gustatory region 
which are especially sensitive to particular stimuli — 
quinine, for example. 

So^Htom. —Through the aid of a probang or a camel's- 
hair brush apply to different limited areas of the 
tongue, palate, or fauces either the standard solu- 



tions given above or somewhat stronger solutions of 
the same .substances. 

Results. — The accompanying figure gives the results 
which coincide substantially with those of other obser- 
vers. 

"O. Ehrwall has examined the different fungiform 
papillae over the tongue with reference to tlieir sensi- 
tiveness to taste stimuli. One hundred and twenty- 
five separate papillae were tested with succinic acid 
quinine, and sugar. Twenty-.sevcn of the papillae gave 
no response at all, indicating that they were devoid of 
taste fibers." [It may be suggested" in passing that 
perhaps the twcntv-seven papilla; were sensitive to 
salt alone.— W. S. II.] 

"Of the remaining ninety-eight, twelve perceived 
acid alone, three perceived sugar alone, while none was 
found which reacted to quinine alone. The fact that 
some papilla; respond to only one form of taste .sen.sa- 
tion is evidence in favor of the view that there are 
separate nerve fibers and endings for each fundamental 
sensation, but a majority of the papilla (eighty-three) 
are provided with more than one variety of taste 
fibers." (Henry Sewall, in ".American Text-book of 
Physiology.") Winfield Scott Hall. 

Tate Spring. — Grainger County, Tennessee. 
Post-office. — Tate Spring. Hotel and cottages. 

Access. — Via Knoxville and Bristol Railroad, con- 
necting with the Southern Railway at Morristown, 
and the Southern R ailway and Louisville and Nash- 
ville Railroad at Knoxville. 

This resort is 1,480 feet above the sea-level, and is 
located in a charming valley in the heart of the Cum- 
berlands, environed by mountains 3,000 feet in 
height. It may be regarded as one of the strictly 
first-class summering places of the Tennessee Moun- 
tains. The main hotel, in the midst of a hundred- 
acre park, with bluegrass lawns, beautiful shade trees, 
and concrete walks, commands a view of fields and 
woodland and mountains of unsurpassed beauty. 
The climate is genial. There is but one spring, which 
yields one hundred and thirty-five gallons per hour. 
The following analysis was made by Childress and 
Hunter, Chemists, Knoxville Board of Health 
Knoxville, Tennessee. 

One United States Gallon Contains: 

Solids. Grains. 

.Ammonium chloride 0.002 

Silica free 1.14 

Silica combined 0.13 

Iron peroxide . 04 

Aluminum oxide . 20 

Calcium sulphate 76.54 

Calcium carbonate 21. 50 

Magnesium sulphate 35-28 

Sodium sulphate 4.40 

Sodium chloride 0.13 

Sodium nitrate 0.02 

Potassium chloride 0.90 

Lithium chloride 0.04 

Calcium phosphate 0.03 

Total solids per L'. S. gallon 140 52 

The water is colorless and transparent. It has an 
acid reaction due to the presence of carbonic acid, 
which enables it to hold in solution some carbonate of 
lime. The specific gravity is 100.3552. The tem- 
perature is 55° F. The "volume and temperature 
never change. 

The analysis shows a saline purgative water with 
tonic and alterative properties. It has been found 
beneficial in functional disorders of tlie nervous .sys- 
tem induced by overwork and mental worry, in cases 
of hj-pochondria and insomnia, in chronic metallic 
poisoning, and in the various manifestations of the 
strumous diathesis. Some forms of dyspepsia and 
liver and kidney disorders are also improved by its 

101 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



use. Other conditions that are benefited by this 
water are diseases of women, rheumatic affections, 
and skin diseases. The water is now used commer- 
cially and shipped by the bottle, case, or barrel to 
anv desired point. 

The hotel is thoroughly modern, and is open 
throughout the year. The table is supplied with 
fresh vegetables from the gardens of the Tate Spring 
Hotel Company, ham, beef, nuitton and poultry 
cured and dressed on the estate, and table water from 
a mountain spring. Golf, dancing, and various other 
amusements are provided for the guests. 

Emma E. Walker. 



Tattoo Marks. — Tattooing consists in the in- 
troduction into the skin of insoluble colored sub- 
stances which become encapsulated and thus form 
permanent stains. Microscopical examination of 
sections from tattoo marks shows that they consist of 
relatively large particles of pigment, situated part of 
them in "the corium, but the larger part in the subcu- 
taneous connective tissue. Particles of pigment are 
found also in the contiguous lymphatic ganglia. 
Powder stains, coal-dust stains, and similar stains 
produced by the accidental embedding in the skin of 
particles of colored substances, usually carbon, are in 
all essential characteristics identical with tattoo marks. 
One form of accidental marking of the skin to which 
attention should be called is the whitish marks which 
occasionally result from the precipitation of lead in the 
tissues during the use of subacetate-of-lead .solution 
or lead and opium wash upon superficial wounds in- 
volving the connective tissue. The danger of these 
stains on the cornea from the use of subacetate of lead 
in the eye is well known. I have seen similar perma- 
nent stains from the use of solution of ferrous sulphate 
(copperas) over surfaces denuded of epidermis. A 
stauiing of the skin which is in all essentials of the same 
character as these we are considering, but which is 
produced from within, is argyria, in which there is a 
precipitation of silver in the derma and subcutaneous 
tissue after the long-continued internal use of silver. 
The writer has seen a marked argyria in one case in 
which the silver w-as not being taken internally, but 
had been used daily during more than a year in the 
form of a solution of the nitrate for painting patches 
of leucoplakia buccalis. 

Tattooing is one of the most primitive efforts of man 
at personal adornment. Like many other things that 
have their origin in vanity, various kinds of signifi- 
cance are attached to the practice, but the underlying 
reason for tattooing, not only among the primitive 
races, but among the civilized, rests probably upon an 
inherent barbaric taste for distinctive personal 
decoration. Among uncivilized peoples and among 
nations in a relatively low state of civilization, like the 
Orientals, the practice is general, and is often carried 
to the most extravagant extent. Among Caucasians, 
aside from its general use among sailors, it is largely 
confined to those individuals of both the lower and the 
higher classes who readily accept anj-thing that is 
bizarre or that gives them a fancied di.stinction. 

Brault divides tattooing among primitive peoples 
according to its significance, as follows: First, religious 
tattooing, as in the priests among the Polynesians; 
second, ornamental tattooing, seen in the Algerians. 
Tunisians, and in the inhabitants of Oceanica and 
Japan; third, therapeutic tattooing, practised in Tunis, 
in Egypt, and in the Congo region; fourth, distinc- 
tive tattooing, practi-sed among the Arabs and negroes 
of Africa, for the puqiose of defining not only difi'erent 
tribes, but also certain callings; fifth, obscene tattoo- 
ing, which is f'ound only rarely among savages, but- 
which is very common among sailors and criminals. 

Practical uses of tattooing are verv limited. As a 
means of identification tattoo marks are of course 
valuable, and the tattooing of habitual criminals has 

102 



been suggested as a means of their ready identifica- 
tion. Several years ago de Wecker suggested the 
tattooing in black of leucomatous areas on the cornea. 
The method has not had very wide application, and 
is of course not free from danger. Very recently the 
highly artificial suggestion has been made of tattooing 
the flush area of the cheeks to represent a healthy 
blush. It is interesting to try to imagine how this 
healthy blush would appear on the faded skin of 
later life. 

Designs of the most elaborate character are often 
seen in tattoo marks, many of them showing some 
artistic taste and considerable technical skill. The 
extent to which tattooing has been carried in some 
individuals has been limited only by the cutaneous 
surface. In the well-known case of the tattooed man 
from Burmah, illustrated in Hebra's Atlas, the entire 
surface was occupied by tattoo marks. Numerous 
other cases of almost as great extent have been seen. 

The usual method of tattooing is first to outline 
upon the surface the design, and then to prick out this 
design with a needle or a bundle of needles, and after 
that to rub in the pigments. For dark blues and 
blacks, carbon in some form is used, charcoal, lamp- 
black, India ink; other pigments used for various 
colors are cinnabar, carmine, indigo, Prussian blue. 
The dangers of tattooing, at the hands of the unskilled 
persons by whom it is usually practised, are by no 
means smaU. All sorts of infections are po.ssible: 
lymphangitis, erysipelas, chancroid, tetanus, tubercu- 
losis, leprosy, and syphilis. Many cases of syphilis 
transmitted by this method are recorded in the litera- 
ture. The means of transmission — by the saliva of 
the operator, the use of an infected needle, subsequent 
infection of the unhealed wound — are manifest. 

Much ingenuity has been exercised in attempts 
successfully to remove these marks. The treatment 
of powder stains and similar stains is largely a matter 
of mechanical removal, and to be successful this must 
be done immediately after the production of the 
marks, before the particles of pigment have become 
so disintegrated that their mechanical removal is im- 
possible. The individual masses of pigment have to 
be patiently picked out, for which purpose an iris 
needle or a small sharp-pointed knife is most conven- 
ient. The method requires great patience both on 
the part of the operator and on that of the patient, 
but if thoroughly done immediately after the injury 
it gives satisfactory results. A certain amount of 
anesthesia may be obtained by the application of 
small quantities of weak cocaine solution or by the 
use of an ointment of ten- to twenty-per-cent. ortho- 
form in lanolin. In connection with the mechanical 
removal of the particles of pigment, the use of a strong 
solution of HoOo-as a bleaching agent has been sug- 
gested, and it is perhaps the best antiseptic for use in 
these cases; but it is hardly possible that powder 
stains or coal-dust stains could be bleached by this 
means, since at the body temperature carbon (which 
causes most of the discoloration) cannot be bleached 
with oxygen. 

The principle of almost all of the methods for the 
removal of tattoo marks is their destruction by mechan- 
ical means or by the production of a destructive 
inflammatory process which causes a superficial 
eschar. Very small stains can be destroyed by the 
use of the cutaneous punch or b.v electrolysis or by 
excision. In using electrolysis the needle attached 
to the negative pole of a battery with a current of 
from two to ten milliamperes is inserted at various 
points around the periphery of the marks, and a 
sufficient reaction is produced to cause the destruc- 
tion of the involved tissue. In a few days after the 
application a dry superficial eschar forms, which is 
thrown off, leaving a white scar. Of course these 
mechanical methods can only be applied to very small 
lesions on account of the scars which they produce. 
The various methods for the treatment of larger 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



lesions depend upon the application of some irritant 
which sets up an acute inflammatory process suffi- 
ciently intense to cause destruction of the superficial 
layers of the skin. Many irritants have been sug- 
gested for this purpose: chromic acid, carbolic acid, 
acetic acid, tincture of cantharides, potassium nitrate, 
etc. The two methods of treatment after this 
principle which have been most definitely worked 
out are those of Variot and Brault. 

Variot's plan of treatment, according to Brocq, is 
as follows: First, he places on the tattoo marks a con- 
centrated solution of tannin, and tattoos this in. 
Then a silver-nitrate pencil is rubbed vigorously over 
the surface. The action of the silver nitrate is 
allowed to go on for some moments until the surface 
becomes black from the formation of silver tannate 
in the superficial layers of the skin. In the next few 
days a slight inflammatory reaction occurs, and over 
the surface treated a closely adherent dark crust 
forms. After the third or fourth day there is no pain 
except when there is movement of the muscles under 
a large crust. Occasionally there is a little suppura- 
tion under the crusts, but if secondary infection is 
avoided no severe inflammation occurs. After four- 
teen or sixteen days the crust comes off spontaneously, 
the corium and the epidermis underneath have been 
repaired, and the locality of the mark is recognizable 
only by a superficial pink cicatrix which gradually 
becomes of normal color. A couple of months after 
the operation the scar is hardly noticeable. 

In Brault's plan the irritant used is a solution of 
chloride of zinc, thirty grams, to forty grams of 
water. The mark is tattooed with needles dipped 
in this solution, and in addition the surface is lightly 
moistened with the same solution after the tattooing. 
A mild inflammatory reaction is produced, followed 
by the formation of a crust which subsequently 
exfoliates, leaving a pinkish, slightly scarred surface 
similar to that after Variot's operation. 

In the use of either of these methods several 
attempts may be necessary. The surface treated at 
one time should not exceed one or two square inches, 
and of course ordinary surgical precautions as regards 
the cleanliness of the surface, both before the opera- 
tion and during the subsidence of the inflammatory 
process, should be observed. Both of these methods 
are founded upon correct pathology and are worthy 
of trial. Variot's method would seem the one of 
preference, as the action of silver nitrate can be more 
accurately controlled than that of zinc chloride. 

William Allen Pusey. 



CHj-NHj 
Taurine, oramino-ethvlsulphonicacid I 

CHjSOjOH 
Taurine is a decomposition product of taurocholic 
acid of the bile. It is a sulphur containing substance 
and as such undoubtedly originates from the cystine 
radical of the protein molecule. Taurine crystaUizes 
from watery solutions in the form of needles. 

F. P. U. 



Taylor, Alfred Swaine. — Born at Northfleet, 
County of Kent, England, in 1806. He studied medi- 
cine at'Ouy's and 8t. Thomas' Hospitals. From 1851 
to 1870 he held the regular Chair of Chemistry in 
the School of Guy's Hospital; and from the latter 
date to the time of his death he gave regularly in- 
struction in medical jurisprudence — a now Chair which 
lie was the first to fill. He died in London May 27, 
1880. 

Taylor may rightly be considered the founder of 
medicolegal science in England, and he certainly 
was one of the most distinguished teachers of this 
branch of medical knowledge. He wrote and pub- 
lished a mmiber of treatises on medicolegal topics which 



were long accepted as the standard authorities in the 
English speaking world. A. H. B. 



Taylor, Charles Fayette. — Born in WilUston, 
Vt., on April 2.5, 1827, ho was graduated from the 
medical department of the University of Vermont 
in ,June, 1856. Soon after receiving his medical 
degree he went to New York City to investigate a 
system of exercises relative to orthopedic work, in 
which branch of medicine he had evinced a decided 
interest. Not satisfied with the results he travelled 
on to London and there studied the movement cure 
under Dr. Roth, who was the representative of this 
method. He returned to America in 18.58 and de- 
voted himself to the practice of orthopedics, introduc- 
ing not only the movement cure, but also many e.xer- 
cises which he had originated and developed. He 
became widely known on account of his successful 
treatment of orthopedic cases, and as his work grew. 
Not being able to find the proper types of apparatus 
for his use, he invented many such machines for 
resistance exercises and especially for the treatment 
of spinal and joint conditions. " Taylor'.s apparatus," 
a steel spinal support in Pott's disease, and Taylor's 
hip splint are still in use. He believed largely in 
producing in his patients a cheerful mental attitude, 
hence his treatments included what is now termed 
mental hygiene, as well as orthopedic exercises. In 
1866, he founded the New York Ortliopedic Hospital 
and Dispensary. He was Attending Orthopedic 
Surgeon at the hospital which he founded and also at 
St. Luke's Hospital. He died in Los Angeles, Cal., 
January 25, 1899. 

Dr. 'Taylor's career in medicine stands for remark- 
able advancement of orthopedic science in this country 
and recognition of the same abroad. He was the 
first to practise kinisepathy, or the movement cure, 
here, and his great originality did much toward the 
improvement of orthopedic treatment. In 1867 he 
was honored with medals and diplomas at the Exposi- 
tion of Paris; in 1873, the Vienna Exposition, and in 
1876 the Centennial Exposition of Pliiladelphia 
bestowed upon him similar medals and diplomas for 
his services in the treatment of cripples. 

From 1857 Taylor was a frec|uent contributor to 
medical literature. His first article, "Cure of Dis- 
eases by Movements," was published in the Medical 
World, January 14, 1857. Among his other writings 
were: " Treatment of Lateral Curvature of the Spine 
by Specific ExercLses," New York, 1859; "Theory 
and Practice of the Movement Cure," 1861; "The 
Pathology and Treatment of Lateral Curvature of 
the Spine," Bulletin, N. Y'. Academy of Medicine, 
1868; "Spinal Irritation or Causes of Backache Among 
-American Women," Wm. Wood & Co., New York, 
1868; "Is There Any Therapeutic Value in the So- 
called Localized Movements?" Medical Record, 
August 15, 1870; "Emotional ProdigaUty," Dental 
Costnos, July, 1879; and "Climate and Health," 
Popular Science Monlhhj, July, 1891. E. L. J. 



Tea. — {TM, Codex Med.) The prepared and dried 
leaves of Thea sinensis L. {Camellia tliea Link, Fam. 
Theacece). This definition includes, as varieties 
Thea (Camellia) viridis, T. bohea. and others, as well 
as the wild Assam tea tree, supposed to be the origin 
of them all. The tea plant as seen under cultivatioi; 
is a shrub, a meter or so in height (from two to five 
feet), but in the wild state it becomes a small tree of 
from five to ten meters. The leaver are alternate, 
evergreen, rather thick and leathery, smooth when 
mature, short-pctioled, lanceolate, of varying blunt- 
ness, serrate, feather-veined, the veins not reaching 
the margins, and from five to ten centimeters, or in 
the much larger wild plant, from fifteen to twenty 
centimeters long. 

103 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



Tea is a native of Asia, and grows in a senii-wiUl 
staU" in numy of the districts where it is cultivated, 
but lias only been found in an unquestionably in- 
digenous condition in Assam, where it was discovered, 
by Mr. Robert Bruce, as a good-sized tree with very 
large leaves. It is now cultivated in many parts of 
the world; first in importance in China, where it is 
said to have been domesticated more than a thousand 
years ago, also in great quantity in Japan, Java, and 
India, to a slight extent in South America and else- 
where, and finally in the United States, experimen- 
tally. Although "it grows pretty well in many places 
and" is comparatively hardy, the higher price of labor 
is a bar to its profitable production in most civilized 
countries. 

The earliest knowledge of the use of tea is from the 
Chinese, to whom it was familiar one thousand and 
perhaps two thousand years ago. It was introduced 
into Japan in the thirteenth century a.d., and into 
Java and India in recent times. It was first used in 
Europe near the middle of the seventeenth century. 

Tea is planted in gardens and tended without 
gathering until two or three years old; then the leaves 
and buds are plucked for two or three successive crops 
each season. If green tea is to be made, they are 
immediately dried over a heated stove, and after- 
ward colored more or less. For black tea the leaves 
are pressed in little heaps, and allowed to wilt and 
ferment a little before drying, w hieh is effected in the 
same way as above; by tliis procass some of the 
tannin is decomposed, and the essential oil altered 
so as to modify the taste and smell a little; its color 
is also very much darkened, as well as that of the 
infusion m.ade from it. The principal varieties of 
tea are: Black — flowery pekoe, orange pekoe, 
souchong, congou, bohea, etc. Green — gunpowder, 
imperial, hyson, young hyson, etc. The teas of our 
market are nearly always "blends," made by mixing 
several grades together. 

The usual shape of tea is attained by compressing 
and rolling the leaves in the hand or upon a table 
until they are cnunpled into the little rolls or wads 
of which commercial tea consists; in the nicer sorts 
each leaf is rolled by itself. 

Composition. — In the proportions of the ingredients 
there is considerable variation, but the following are 
the principal ones: Essential oil from one-half to one 
per cent., which is the source of its flavor; caffeine 
(theine) from one-half to two or three per cent., which 
gives it bitterness. This alkaloid is found in half a 
dozen other plants, most of which are used somewhere 
as stimulating food adjuncts (see Caffeine, Guarana, 
Coin Nuts, etc.). It is also related to cocaine and 
theobromine. The amount of tannin in tea is large 
(from twelve to se\'enteen per cent.). 

Action ast) Use. — The large amount of tannin found 
in tea makes it an active astringent, especially to those 
unaccustomed to its use. It constipates the bowels, 
impairs the digestion, and reduces intestinal secre- 
tion when taken in large quantity; locally it makes tea 
a mild hemostatic, anrl a useful wash for indolent 
ulcers, exuberant granulations, etc. The essential 
oil gives to tea its agreeable flavor and a good part 
of its exhilarating character; it relieves fatigue, 
stimulates thought, postpones sleepiness, and cheers 
the mind. The caffeine is the chief mental and 
nervous stimulant and cardiac tonic element. By 
long-continued, habitual use neither of the above 
eftecU is much felt, unless carried to the extent of 
diminishing the appetite and developing dyspeptic 
troubles. 

The least desirable of the constituents of tea is the 
ianniii; it is also one of the slowest to dissolve out, and 
can, therefore, with a little care, be largclv left with 
the dregs. The (luicker an infusion of tea is made, the 
more fragrance and less bitterness and astringency 

104 



it has; .and the more slowly, the more tannin. Tea 
for drinking should be made by pouring boiling water 
into a suitable vessel containing the tea and allowing 
it to stand for from five to ten minutes, no longer. 
A better way is to rinse the cup in boiling or very 
hot water until it is heated through, then put in a 
teaspoonful of Ary tea, fill the cup with boiling water, 
and allow to stand a few minutes. Tea should never 
be l)oilcd or stand long unless the tannin is wanted. 
If made in an iron vessel or in a tin one which has 
begun to wear, it will become dark from the formation 
of a bitter tannate of iron. On account of its almost 
universal use over the entire world, tea is not often 
available as a medicine; its effects are identical with 
those of coffee, but perhaps more astringent and less 
stimulating than that article. As is the case with 
coffee, the commercial value of tea depends more 
upon its aroma than on the amount of caffeine it 
contains. 

Allied Plants. — There are a dozen or more species 
of Thea, one of which is Thea japonica, the beautiful 
camellia of the gardens. Besides this there is nothing 
of economic importance in the order. 

Henry H. Rosby. 



Teeth. — Anatomy. — The teeth are commonly 
divided into two sets, according to the period of their 
eruption. The teeth which erupt first are variously 
designated as the deciduous, the temporary, the milk, 
or t he primary teeth. The teet h erupting subsequently 
to the first set are called the permanent or secondary 
teeth. In addition to these there are supernumerary 
teeth, which usually occur in connection with the per- 
manent, but may, in rare instances, he found with the 
temporary teeth; and there are so-called third denti- 
tions, the genuineness of which, though fairly well 
established, is not without question. 

The permanent teeth are thirty-two in number, 
sixteen being placed in the upper, and sixteen in the 
lower, jaw. In each jaw there are four incisors 
(two central and two lateral), two canines, four bi- 
cuspids, and six molars. 

A formula to express the number of the various 
teeth in each jaw is written as follows: If, C|, Bic. $, 
molars | = 32. 

The teeth of the upper jaw are symmetrically ar- 
ranged along the alveolar margin of the superior max- 
illary bones. When viewed from below, their crowns 
are found to describe a parabolic curve. This curve, 
however, varies according to nationality, heredity, 
and accidental circumstances. The teeth of the lower 
jaw are arranged along the alveolar margin of the in- 
ferior maxillary bone, and their crowns describe a 
curve similar to that found in the upper jaw. This 
curve, however, is more pointed in front and more di- 
vergent behind. Speaking roughly, tlie masticating 
surfaces of the teeth of each jaw lie in a single plane, 
no crown projecting in a marked way beyond its 
neighbor. The teeth, also, when normally arranged, 
show no gap in the row, each tooth thus by its position 
giving and receiving support. In both these respects 
human teeth contrast strongly with those of the 
lower animals. In these it is common to find that 
certain teeth, as the canines in the carnivora, present 
a marked elongation, and also that between the 
teeth there occur intervals which allow of their inter- 
locking. 

The curve on which the upper teeth of the perma- 
nent set are arranged is normally somewhat larger 
than that of the lower teeth. In consequence, the 
anterior superior teeth overlap the anterior inferior 
teeth, as do also to a slight extent the superior bicus- 
pids and first and second molars the corresponding 
lower teeth. The wisdom teeth, however, meet 
practically edge to edge. It is to be further noted that 



REFEREN-CE HANDBOOK OF THE MEDICAL SCIENCES 



the superior teeth are not situated directly opposite 
corresijonding inferior teeth. The superior centrals 
are opposite the inferior centrals and a portion of the 
inferior laterals; the superior laterals are opposite a 
part of the inferior laterals and a part •of the inferior 









Fig. 4721. — The Permanent Teeth (slightly reduced in siie), eh 
Surfaces. The middle row of teeth represents freshly erupted i 
fuhprcles on their cutting edges intact. (Carabelli.) 

canines; the superior canine occludes between the 
inferior canine and the first inferior bicuspid; the 
lirst superior bicuspid occludes between tlic first and 
the second inferior bicuspids; the second superior bi- 
cuspid occludes between the second inferior bicuspid 



and the first molar; the first superior molar occludes 
with the first and the anterior portion of the second 
inferior molar; the second superior molar occludes 
with the second and the anterior part of the third 
inferior molar; the third superior molar occludes with 
the third inferior molar, and is 
the only tooth in the upper jaw 
having a single antagonist. 
While it has been stated that 
the masticating surfaces of the 
teeth of the upper and lower 
jaws are on a single plane, 
yet slight deviations from this 
rule are to be noticed. If we 
follow the lower edge of the 
upper t^eth from a superior 
central around to the wLsdom, 
we shall find that the line as- 
cends gently from the central 
to the interval between the 
first and second bicuspids, then 
descends till past the first 
molar, when it ascends slightly 
to the end of the row. On the 
lower jaw the anterior teeth 
are slightly elevated above the 
posterior, and between the 
canine and the wisdom tooth 
a slight convavity is to be ob- 
served. 

In its description a tooth is 
to be divided into a crown, 
a root or fang, and a neck. 
The crown of a tooth is that 
part which normally appears 
beyond the margin of the gum. 
The root or fang is that part 
which is normally embedded 
in the alveolus of the ma.\illary 
bone. The neck is a more 
or less constricted belt lying 
at the margin of the gum where 
the crown joins the root. The 
surfaces of the crowns are thus 
designated. Those surfaces 
lying adjacent to the lips are 
called labial surfaces, those 
lying adjacent to the bucci- 
nator muscle are called buccal 
surfaces. Those surfaces on 
the inner side of the teeth 
lying adjacent to the tongue 
are called lingual surfaces. In 
the case of the upper bicuspids 
and molars, however, such sur- 
faces are more commonly called 
palatal surfaces, from their re- 
lation to the hard palate. The 
grinding surface of the bicus- 
pids and molars is called the 
occlusal surface. The sur- 
faces between adjoining teeth 
are called approxiinal surfaces, 
and are <livided into two chisses 
— mesial and distal. The me- 
sial approxiraal surface of a 
given tooth is that surface 
which, were the row of teeth 
in a straight line, would face 
toward a line drawn between 
the central incisors. The dis- 
tal approxiinal surface is the 
corresponding surface at the opposite side of the 
tooth. These names are, as a rule, applie<l to the 
crowns of the teeth, though they arc, with the excep- 
tion of the term coronal, used also in connection with 
the roots. 

105 



wing the Labial and Buccal 
iicidors and canines, with the 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



The tcmpoTary lecth are twenty in number. In 
each jaw there are four incisors, two canines, and four 
molars. The dental formula is I{, C|, molars i = 20. 

This formula dilTers from that of the permanent 
teeth by the entire absence of bicuspids, and by the 
loss of four molars. The temporary teeth can best be 
described by comparing them with the permanent 
teeth, which thev closely resemble. 

The incisors and canines of the upper and under 
jaws are very much smaller than the corresponding 
teeth in the permanent set, and the root of the upjier 
central incisors is somewhat curved on the mesial 
side where the corresponding root in the permanent 
teeth is practically straight. 

The first upper molar is situated behind the canme, 
and in appearance is a compromise between a bicuspid 
and a molar. Its crown resembles in general shape 
that of an upper molar, but is quite small, and bears 
only three cusps — two external and one internal. 
The roots are three in number, resembling in shape and 
position those of the permanent molars. They are, 
however, more divergent, thus providing room for the 
first bicuspid, whose crown is situated directly be- 
neath the temporary tooth, and within the grasp of 
its roots. 

The second upper molar is a much larger tooth than 
the first, and resembles so closely the first permanent 
molar that it might be mistaken for it. Its roots are 
more divergent, however, in order to embrace the 
crown of the second bicuspid, to which it gives way in 
the permanent dentition. 

The first molar in the lower jaw is situated behind 
the canine, and resembles in shape a permanent 
molar of the lower jaw. Its crown is surmounted by 
four cusps — two external and two internal. It has 
two roots, one anterior and one posterior, between 
which is developed the crown of the first inferior 
bicuspid. 

The second lower molar is larger than the first, and 
a little smaller than a permanent lower molar, which 
it closely resembles. Its crown has five cusps — three 
external and two internal. There are two roots, one 
anterior and one posterior, which embrace the de- 
veloping crown of the second lower bicuspid. It is 
characteristic of the temporary teeth that the foramen 
at the apex of the roots is larger, that the necks of the 
teeth are more constricted, and the color whiter and 
more delicate than in the permanent teeth; also, that 
the six anterior upper teeth do not overlap the corre- 
sponding lower teeth to such an extent as in the 
permanent set 

Microscopic Anatomy of the Teeth. — A longi- 
tudinal section through a tooth will reveal four dis- 
tinct structures — the enamel, the cement, the dentine, 
and the jjulp. The pulp is a soft mass of connective 
tissue richly supplied with blood vessels and nerves, 
and located in the center of the tooth. It fills the 
pulp cavity. The pulp cavity starts at the apex of 
the root or roots, as the case may be, as a thread-like 
canal, and gradually enlarges till it reaches the crown, 
where it attains its greatest size; throughout its whole 
course it imitates in shape the externalcontour of the 
tooth. An artery and nerve, and sometimes more 
than one of each, enter the apical foramen of each root 
of a tooth, and, branching freely, distribute themselves 
to all parts of the pulp, being especially abundant 
about its periphery. A venous system "returns the 
blood through the apical foramen into the general 
circulation. It is a matter of dispute whether a 
lymphatic system is present or not; most observers 
consider that it is not. Around the periphery of the 
pulp, and distinct from the connective-tissue cells 
forming its body, there exists a layer of cells called the 
odontoblastic layer, or the membrana eboris. In 
shape these cells are large in comparison with the 
connective-tissue cells; they are of columnar form and 
have several processes. By the lateral processes they 

106 



are in contact with each other, while the longest process 
extends into the dentinal tubule and becomes a 
dentinal fibril. 

Immediately surrounding the pulp comes the 
dentine, which is the most abundant tissue of the 
tooth. It is hard and dense in structure, of a yellow- 
ish-white color and silky luster. On analysis it is 
found to contain animal matter, twenty-eight per 
cent.; earthy matter, seventy-two per cent. Its 
various components are thus given by von Bibra: 

Per cent. 

Organic matter 28 . 01 

Phosphate and fluoride of calcium 66 . 72 

Carbonate of calcium 3 . 36 

Phosphate of magnesium 1.18 

Other salts 73 

Total 100.00 

Morphologically considered, it is composed of a 
structureless matrix permeated by countless tubules, 
each tubule possessing a lining membrane and a central 
fibril. The tubules start from the pulp cavity, where 
they have a diameter of about ^An of an inch, and 




Fig. 4722. — The Temporary Teeth, natural size, showing their 
Arrangement in the Maxillary Bones, and Relations to one An- 
other. (Carabelli.) 

radiate toward the periphery of the dentine, becoming 
smaller and more numerous as they advance. While 
the direction taken by the tubules in different parts 
of the tooth varies greatly, yet contiguous tubules 
are essentially parallel. Two or three undulatory 
curves are to be noticed in the length of a tubule, and 
the name primary curvature has been attached to 
them. Numerous spiral turns occurring in the course 
of the undulatory curves have been named the sec- 
ondary curvatures. The tubules give off frequent 
branches throughout their entire length. Some of 
these branches are important, extending to the outer 
layers of the dentine parallel to the main channel. 
Other branches serve merely to connect one tubule 
with another, and still others are blind processes. 
At the outer layer of the dentine the tubules become 
diminished in size and very numerous. Some of the 
tubules can be seen entering the granular layer of the 
dentine, while others either terminate blindly or 
anastomose with neighboring tubules. The tubules 
of the dentine have been shown to possess a lining 
membrane, and to this the name dentinal sheath has 
been applied. This structure resists the action of 
reagents which destroy the matrix in which the tubules 
are embedded, and is supposed to consist of ela.stic 
tissue, though its composition is not surely determined. 
The dentinal fibril occupies the center of the tubule, 
and is a soft homogeneous substance; it is one of the 
processes of the odontoblasts. It extends through 
the dentinal tubule to the periphery of the dentine 
and gives off branches into the branches of the 
dentinal tubules. These fibers were thought to 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



have a nerve-like function, but lately it has been 
proven (Deppendorf) that they contain nerve fila- 
ments which encircle the fibers in arm-like fashion. 




The dentine is surrounded in the crown by the 
enamel, and in the root by the cementum. 

The cementum, or crusta petrosa, is the outer cover- 
ing of the root. It Ls thinnest at the neck of 



4723. — The Temporary Teeth, natural size, showing the External and 
Internal Surfaces. (Carabelli.) 

Tliese filaments are branches from the nerves of the 
dental pulp and can be seen passing through the 
odontoblastic layer where they were for- 
merly thought to end. At the periphery 
of the dentine we find that the nerve 
fibrils anastomose or form small ring- 
like endings. 

The dentine is developed by stages, 
a fact made apparent b}' treating it with 
hot caustic potash. By this reagent the 
dentine becomes separated into layers, 
which cross the tubuli at right angles, 
and are concentric about the pulp. In 
the crown of the tooth between one 
BicusoicTwith^ layer of dentine and another, there oc- 
in the grasp of ^^^ imperfectly calcified spots where 
its Roots, the dentine assumes a globular form, 
{ Wedl.) and where irregular interglobular spaces 

are found. Series of minute interglob- 
ular spaces give rise to the "incremental lines of 
Salter." 






tion through the pulp 
belli.) 



Flo. 4726. — A Microscopic Section of a Canine 
Tooth, showing, A, the enamel, with its enamel rods 
running from the dentine to the outer surface. The 
dark strips indicate places where the enamel rods cross 
each other. The fine parallel linos are the " brown lines 
of Rctzius." B is the dentine, with its tubules radiat- 
ing from the pulp cavity. The undulatory curves of 
the tubules are called the primary curvatures. The 
secondary curvatures are not visible at this enlarge- 
ment. The granular layer is indicated by the dotted 
line about the periphery. It is especially marked 
between the cement and dentine, and practically 
absent between the enamel and dentine. The inter- 
globular spaces are represented in the coronal por- 
tion of the dentine just removed from the junction of 
the dentine and enamel. C indicates the cement, with 
its lacuns and canaliculi. 

the tooth, where it meets and slightly over- 
laps the enamel, and grows gradually thicker 
toward the apex, about which point it is 
most abundant and its structure is most 
perfectly developed. Cement has essen- 

107 



referknc;e handbook of the medical sciences 



tially bone stnuture; it possesses lacunic and eanaliculi, 
but has nnrmallv no Haversian canals. The lacunx 




Fig. 4727. — Cross-section of an Upper Bicuspid Tooth. A, .-I, The root canals; B, the granuli 
of the dentine; C, the cemeutum, showing occasional lacunte; D^ the dentine. 

and canaliculi arc wanting or rare in that part of the 
cement near the neck of the tooth, but about the 
apex of the root they are numerous and well developed. 
The lacuna' lie in parallel planes encircling the pulp 
cavity, their canaliculi anastomose freely with each 
other, and in some cases they connect with the 
granular layer of the dentine, thus establishing a 
communication between the lacunse of the cement and 
the pulp of the tooth through the granular layer and 
tubuli of the dentine. 

Immediately surrounding the cementum of the root 
exists the peridental membrane, which is identical 
■with the periosteum which lines the bone forming the 
socket of the tooth. The peridental membrane serves 
a triple function. It nourishes the bone of the socket 
and the cement of the root, besides forming a bond of 
union between the root and its socket. The peri- 
dental membrane, like all periosteum, is composed of 
connective tissue richly supplied with blood-vessels. 
The arterial supply comes from capillaries of the gum 
about the neck of the tooth, from the deep sub- 
stance of the bony socket, and from a branch of the 
artery entering the apical foramen of the tooth. 

The enamel forms the outer covering of the crown; 
it is the hardest structure in the body. It resembles 
dentine in its chemical constituents, "but has a much 
greater proportion of inorganic material. The follow- 
ing analysis is given by von Bibra: 

Per cent. 

Phosphate and fluoride of calcium 89 . 82 

Carbonate of calcium 4 . 37 

Phosphate of magnesium 1 . 34 

Other salts 0.88 

Cartilage 3.39 

Fn' 0.20 

Total 100.00 

The proportion of organic and inorganic matter is 
as follows: 



Organic 
Inorgani< 



Per cent. 
3.5 
96 9 



Total 100.0 

Morphologically considered, enamel is composed 
of rod-like, hexagonal prisms, arranged side by side, 
one end of the prism resting on the outer layer of the 



crown of the tooth. Each prism extends, as a rule, 
through the entire thickness of the enamel. There 
are some, however, which 
extend only from the cen- 
ter of the enamel to its 
free surface, thus prevent- 
ing gaps which would 
otherwise occur, the outer 
surface of the enamel be- 
ing of greater extent than 
the inner. In diameter 
the enamelprisms measure 
ro'oo to zihji of an inch. 
I'jach prism, when iso- 
lated, lias slight varicosi- 
ties and presents a striped 
appearance similar to 
muscular fi b e r. The 
prisms run, in general, 
parallel to each other, and 
in a wavy course; their 
inner ends are implanted 
in slight hexagonal de- 
pressions in the surface 
of the dentine, and their 
outer ends are received 
layer into similar depressions in 
the under side of the cuti- 
cle of the enamel when 
the cuticle is present. A vertical section of the enamel 
shows that it is thickest in the crown, especially in the 
region of the cusps, 
and becomes thin- 
nest at the neck of 
the tooth, where it 
is overlapped by the 
cement of the root. 
The enamel prisms 
are seen to leave the 
outer surface of the 
dentine at right 
angles, and radiate 
toward the external 
surface of the tooth. 
The general yellow- 
ish-white color of 
the enamel is varied 
by dark bands ex- 
tending vertically 
from the dentine to 
the free surface of 
the enamel, caused 
by the crossing of 
bundles of enamel 
prisms. Certain 

delicate lines run- 
ning longitudinally 
through the sub- 
stance of the enamel 
are also to be no- 
ticed. These are 
called the "brown 
lines of Retzius," or 
contour lines. They 
mark the prog- 
ress of calcification 
of the enamel which 
starts at the cutting 




of Di- 



4728.— .\ Sectic 
and Cement. 1. The cement with its 
lacunae and canaliculi; 2. granular layer 
of the dentine; it is to be noticed that 
^ the lacuHEB communicate with the cells 
edge or cusps of the of the granular layer; 3, tubuli of the 
tooth. Each rest dentine, showing their diminution in 
size as they go toward the cement, 
also their frequent anastomoses and 
their connection, in some cases, with 
the cells of the granular layer. (Quain.) 



of development is 
recorded by a line 
giving a similar ap- 
pearance to the cir- 
cular rings of wood fiber. Also between enamel rods, 
usually near the surface of the dentine, are found 



dentine and the other forming the free surface of the | irregular cavities due to an imperfect calcification of 
108 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



the enamel. On cross-section the enamel has the ap- 
pearance of a mosaic pavement, each prism showing 
its hexagonal shape. 

The cuticle of the enamel, or Nasmyth's membrane, 
is to be found in a freshly erupted tooth. It consi.sts 
of a delicate epithelial covering which encloses the 
enamel; it is, however, so delicate that in the slightest 
use it is worn away. It receives in hexagonal depres- 
sions on its under side the outer ends of the enamel 
prisms. 




& 

Fig. 4729.— Enamel Prisms. Magnified 350 diamotors. 
X Sijows the varicosities and striations of tlie prisms; B 
is a cross-section of enamel, showing the hexagonal shape 
of the prisms, and their tessellated appearance. (Quain.) 

Time of Eruption of the Teeth. — The first den- 
tition begins about the seventh month, and is com- 
pleted about the twenty-fourth month. The second 
dentition begins about the sixth year, and is completed 
about the twenty-first. Considerable variation exi.sts 
in the time at which individual teeth erupt, and no 
date can be absolutely fixed for the appearance of a 
given tooth. It is po.ssible, however, to state the time 
when the eruption of a tooth is normally to be expected 
and the following tables are appended: 

Temporary Teeth. 

The central incisor erupts at the 7th month. 

The lateral incisor erupts at the 9th month. 

The first molar erupts at the 12th month. 

The canine erupts at the 18th month. 

The second molar erupts at the 24th month. 

Permanent Teeth. 

The first molar erupts at the 6th year. 

The central incisor erupts at the 7th year. 

The lateral incisor erupts at the 8th year. 

The first bicuspid erupts at the 9th year. 

The second bicuspid erupts at the 10th year. 

The canine erupts at the 1 1th year. 

The second molar erupts at the 12th year. 

The third molar erupts at the 17th to 21st year. 

As a rule, in both the first and second dentitions the 
lower teeth erupt before corresponding teeth in the 
upper jaw. 

Physiology op the Teeth. — Under this head we 
naturally consider the purposes for which teeth exist, 
and lujw they perform their several functions. The 
subject may be divided into three heads: 

(1) The "function of the teeth in facial expression. 
(2) The function of the teetli in mastication. (3) 
The function of the teeth in articulation. 

The importance of the teeth in facial expression be- 
comes apparent when we consider the effect of their 
ab.sence, as shown in aged people. In such the lower 
jjart of the face has lost the round and graceful lines 
of early years; the chin is pointed, and ai)i)r(ixiinates 
tlie end of the nose; the lips are retracted and llahby, 
and a characteristic hollow extends along tlio cheek. 
When present, each tooth aids in sustaining the proper 
proportions of the face. The upper front teeth, by 
licing slightly in advance of the lower, produce that 



slight projection of the upper lip beyond the lower, 
found In normally shaped features. The bicuspids and 
molars, by their apposition, fix the relation of the lower 
to the upper jaw, and by their bulk give fulness to 
the cheeks. The bony alveolus, also, in which the 
teeth are embedded, has an important relation to 
facial expression, for when a tooth has been lost its 
bony support, being no longer needed, is absorbed, 
and thus the features are still further deprived of 
support. 

The function of the teeth in ma.stication is the most 
obvious and important. Standing as they do at the 
entrance to the digestive 
tract, it is their duty to seize 
upon food, sever its coimec- 
tion with its surrounrlings. 
and comminute it so that it 
can be acted upon readily by 
tlie various digestive fluids. 
The act of seizing and cut- 
ting is performed by the six 
anterior teeth, whose edges, 
by the protrusion of the 
lower jaw, are brought oppo- 
site to each other. When 
once a morsel of food has 
been detached by the an- 
terior teeth, it is passed back- 
ward by the tongue and 
cheeks, to be operated upon ^'"j'J|,.f.';^°|;'' 1"^^, 
by the bicuspids and molars. 
The bicuspids are fitted both 
to cut and to grind. They 
cut by the outer cusps of op- 
posing teeth meeting and passing each other like the 
blades of a pair of scissors. They crush by a lateral 
motion, the crowns of the lower bicuspids moving 
across those of the upper. The function of the molar 
teeth is to crush and grind, for which purpose they are 
fitted by their broad crowns. They crush by means 
of an up-and-down movement, and grind by a lateral 
movement. 

The function of the teeth in articulation is best 
understood by a brief survey of the mechanism of 
speech. This mechanism includes the vocal cords, 




Flii. 4730.— The first pro- 
file represents the features 
undisturbed by lose of teeth. 
nU the 



hich the lips fall in 
lin becomes point 
clined toward the i 



ndthc 




Fic 4731. — Illustrates the Impaction of a Iligbt Superior 
Lateral (o), which lies in the superior maxillary bone at right angles 
to its normal position. (\Vedl.) 

and a resonant cavity above the cords, formed by the 
Ijharynx and the oral and nasal cavities. This 
resonant cavity reinforces and modifies sounds made 
by the vocal cords. Articulation is concerned with 
sounds of two kinds — vowels and consonants. The 
vowels are musical notes formed by the vocal cords, 
and given quality or timbre by the size and shape of 
the air column in the resonant cavities above. The 
consonants are sounds produced by the same 
mechanism, but due to irregular vibrations, and 
hence are noises. The oral cavity, being able to 

109 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



change its size and shape in numberless ways, is tlie 
most important agent in sound modification. 

To produce articulate sounds the cohimn of air 
must be obstructed and forced into channcls'of defi- 
nite size and shape. The column of air is obstructed 
in tlirce ways: first, by applyinp; the back of the tongue 
to the palate; second, by applying the tip of the tongue 
to tlie posterior surfaces of the anterior teeth; and 
third, by a closure of the lips. It is forced into 
definite " channels by pressing the tongue against 
different parts of the roof of the mouth, and against 
the inner surface of the upper teeth. 

Pathology of the Teeth. — Pathology in the Num- 
ber of Dentitions and their Time. — While two is the 
normal number of dentitions, much can be heard and 
read of a third dentition, the authority for which, 
however, rests, as a rule, with unscientific observers, 
and is of very little value. 

The entire absence of one or both of the normal 
dentitions is an estahli^Iif'd f.ict; such cases, however. 




Fio. 4732. — .\ Conical Supernumerary Tooth Located between the 
Superior Central Incisors. (Carabelli.) 

are decidedly rare, especially tho.se in which neither 
dentition has occurred. There is usually associated 
with this condition a failure in the growth of hair 
throughout the body. The condition of the alveolar 
ridge in such cases is similar to that which ensues 
on the extraction of the permanent teeth. Artificial 
substitutes, however, are not always necessary, inas- 
much as the gum, in such cases, is very tougli, and 
capable of performing with remarkable facility the 
duties of mastication. 

Pathology in the Time of Dentition. — The deciduous 
teeth are in rare instances erupted at birth. When 
deciduous teeth are delayed in their eruption it Is com- 
monly due to rickets. A delay in the eruption of the 
permanent teeth is also frequently noticed. An im- 
portant cause for this delay is the prolonged retention 
of the deciduous teeth, an obstacle being thus present 
which prevents the permanent teetli from taking their 
place. Cases are on record of deciduous teeth per- 
sisting till middle or old age. It often happens, how- 
ever, that a permanent tooth is kept from eruption 
because Its place has been taken by another permanent 
tooth which had an earlier start., and which has occu- 
pied all the available room. This is especially liable 
to happen with the superior canines, on account of 
their coming to the surface after the lateral and the 
first bicuspid have taken their place in the arch. If, 
as often liappens, the temporary canine has been pre- 
maturely extracted, allowing the adjoining teeth to 
close In the gap, or if the arch is unusually narrow, 
or the teeth unusually large — and sometimes the two 
latter conditions exist together — then the canine is 
likely to be crowded out beyond the arch or to be im- 
prisoned In the alveolus. The canine may be perma- 
nently imprisoned, or until the extraction of a bicuspid 
or lateral incisor offers it a chance to erupt. 

The wisdom teeth are always very lialale to deten- 
tion within the jaw, and their eruption may be either 
prevented or long delayed. This happens from causes 
similar to those just" described with regard to the 
canine. The modern civilized jaw seems to be made 
too short to contain a full complement of developed 
teetli, and, as the wisdom teeth come last, they, 
though of stunted size, are frequently unable to enter 

110 



the arch. Imprisoned or partly erupted wisdom teeth, 
especially of the lower jaw, may cause very serious 
symptoms, both local and reflex. The local symp- 
toms consist of pain and swelling in the vicinity of the 
tooth; the reflex symptoms of neuralgias about the 
head, and a tonic contraction of the muscles which 
close the jaw. In some cases an abscess may be 
formed which, if lacking prompt exit, may open by 
fistula on the outside of the face, at the angle of the 
jaw, or in the neck, or even as low down as the sub- 
clavicular region. Imprisoned canine and incisor 
teeth are sometimes found far from their normal posi- 
tion. Cases are cited in which the crown of the suijc- 
rior canine has penetrated the nasal cavity and the 
antrum; they have also been located in the palatine 
portion of the superior maxillary bone. Lower 
canines have been found with their long axes parallel 
to the body of the jaw, at or near the tips of the roots 
of the inferior lateral and bicuspids. The superior 
lateral may be delayed in its eruption, or imprisonoil 
for want of room in the arch, and may in consequence 
take abnormal positions similar to those taken by the 
superior canine. 

Pathology in Ike Number of Teeth in a given Dentition. 
— In connection with both the first and second denti- 
tions we find at times both an excess and also a defi- 
ciency of teeth. Teeth in excess of the normal are 
called supernumerary teeth. Such may be coincident 
in time of eruption with the teeth in whose neighbor- 
hood they appear, or they may precede or follow. 
Supernumerary teeth are divided into two main classes 
— teeth whose form differs from that of normal teeth 
(conical teeth), and teeth whose form resembles that 
of normal teeth. Supernumerary teeth are not com- 
mon in connection with the first dentition; when they 
occur they are found more frequently in the lower jaw, 
and belong in shape to the second class, inasmuch as 
they resemble the teeth with which they are asso- 
ciated. The duplicate tooth is usually a lower 
incisor, and it takes its place regularly in the arch, 
being erupted at about the same time as its com- 
panion incisor. Supernumerary teeth are more fre- 
quently found in connection with the second denti- 
tion, and are usually located in the upper jaw. 

They as a rule make their appearance just after the 
adjoining tooth is erupted. Conical supernumerary 
teeth are the most common kind. They have the 
same structure as normal teeth, but in shape resemble 
a diminutive cuspid. Their crown, however, has not 




Fig. 4733. — Shows Two Cubic-crowned Supernumerary Teeth, 
Occurring Behind the Upper Central Incisors. (Salter.) 

the angular outline belonging to that tooth, but Is 
cone-shaped, as their name implies. The root is 
round and tapering. These teeth occur most fre- 
quently in connection with the superior incisors. One 
may be located between the two centrals in the arch, 
or between the central and the lateral. They may be 
placed without the arch, on either its labial or palatal 
.side. Conical teeth are not commonly found adjoin- 
ing the molars, bicuspids, or cuspids, though they 
may exceptionally be found in all these localities. 
If found outside the arch, conical teeth are of no value 
and should be extracted; if found in the arch, it often 
becomes a question whether their presence or absence 
produces the greater deformity. Supernumerary 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



tc<'th which resemble normal teeth are generally found 
among the upper incisors and regularly placed in the 
arch; they do not necessarily produce deformity, and 
l)y the unprofessional eye would not be noticed. A 
supernumerary superior lateral is most commonly 
found; next in frequency comes the superior central, 
while duplicates of the superior molars, bicuspids, and 
cmiines are rare. Carl Wedl, in his " Pathology of the 
'rccth," gives a drawing of the superior and inferior 
riiaxilUc of a negro, in which appear four molars on 
lacli side of both the upper and under jaw, besides an 
extra bicuspid in the lower jaw, making five super- 
numerary teeth in all; the molars are all in the dental 
arch, but the bicuspid is situated at the inner side of 
its neighboring bicuspid. A third kind of supernu- 
merary tooth, sometimes described, is called the cubic- 
einwned tooth; it resembles in shape the lower bicus- 
pid, and occurs in the anterior part of the mouth 
behind the superior incisors. 

I'lilhiilngy in the Arrangement of the Teeth. — A patho- 
logical arrangement or irregularity may affect groups 
I if teeth or individual teeth. Among the irregularities 
which affect groups of teeth are cases in which thc^ 
anterior teeth of the upper jaw project so far in 
advance of the corresponding teeth of the under jaw 
that a considerable space exists between the anterior 
surface of the lower teeth and the posterior surface of 
I he upper teeth. This arrangement is in many cases 
liiTcditary, but may be induced by thumb-sucking 
in infancy. Infants addicted to this habit place the 
tliumb between the front teeth and pry the upper 
teeth forward, using the under as a fulcrum. The 
force exerted is very slight, but, being continued for 
j)crhaps several hours during the day, is sufficient to 
move the imperfectly calcified bony alveolus. 

An irregularity the reverse of the above, and of 
frequent occurrence, is produced when the anterior 
teeth of the under jaw are placed in advance of those 
of the upper jaw, leaving an interval between their 
posterior surfaces and the anterior surfaces of the 
su|)crior teeth. To this condition the name under-. 
Iiung jaw has been given. It is usually hereditary, 
and results either from an overdeveloped under jaw 
or from an underdeveloped upper jaw, the under jaw 




,^ >-, 



>>' 



Fie., 1734. — A Cusi.- of Projecting Upper Front Teeth. (Baker.) 

being normal. This irregularity, as well as the one 
first described, is very unfavorable to facial expression. 
The former causes an excessive protrusion of the upper 
lip beyond the under, and the latter a protrusion of the 
under lip beyond the upper. A third irregularity is 
produced when the superior anterior teeth, instead of 
slightly overlapping the inferior anterior teeth, meet 
them edge to edge. This arrangement causes no 
marked facial blemish, but is detrimental to the teeth, 



which become worn away by edge to edge contact, 
and thereby shortened. 

The six anterior teeth of both jaws are sometimes 
tilted forward to a marked degree. This irregularity 
is commonly cau.sed by the loss of molar and bicuspid 
teeth, which allows the whole force of occlusion to 
come upon the anterior teeth. This irregularity 
causes the upper and under lips to protrude. 




173.5.— .\n Undprhuiig .Jaw. the I..iu.t Fr^ 
Vance of the Corresponding Upper Ones. 



(Baker.) 



On the other hand, the six anterior teeth of both 
jaws may be inverted, and a corresponding falling in 
of the lips occur. 

A V-shaped jaw is often seen; this irregularity is 
confined to the upper jaw, who.se alveolar arch, in- 
stead of being in the form of a jiarabola, becomes so 
contracted in front that it resembles in shape the letter 
V. In such a jaw the room for the tongue is much 
diminished, and a thick and somewhat iudisttnct 
articulation may result. 

There are cases in which the back teeth are of undue 
length and prop the mouth open so wide that the 
anterior teeth do not meet. Such an arrangement is 
likely to keep the lips from closing, except as the result 
of conscious effort. 

The dental arch may be asymmetrical. Such a con- 
dition may be congenital, or produced by tongue-suck- 
ing in infancy. In this habit tlic tongue is crowded 
against the alveolus bordering the upper molars and 
bicuspids, a constant repetition of force in this direc- 
tion unevenly spreading and thus distorting the dental 
arch. 

The "flat mouth," so called, is produced when the 
six anterior teeth of both jaws are arranged in nearly a 
straight line instead of in a curve. When so place<i 
they join the bicuspids at a right angle, or nearly so, 
and give a characteristic flatness to the expression 
about the mouth. 

These various irregularities are, as a rule, confined to 
the permanent set. An underhung jaw has. however, 
been noticed in the temporary set, followed by the 
same in the permanent. 

Irregularities of individual teeth are to be explained 
by several causes, of which the most important is the 
occurrence of a small-sized jaw associated with large- 
sized teeth, a small-sized jaw being inherited from one 
parent and large teeth from the other. 

The premature extraction of the temporary teeth 
is responsible for many cases of irregularity. The 
place of each temporary tooth is taken normally by a 
tooth of the permanent set, and, unless the temporary 
tooth remains in situ till the permanent is ready to be 
erupted, there is danger that the place which the per- 

111 



Teeth 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



inaneiit tooth should occupy will be encroached upon 
bv an adjoining tooth. 

" The too long retention of the temporary teeth may 
produce irregularity. In this case the temporary 
teeth become an obstacle to the descending permanent 
teeth, and niav deflect them from their course, forcing 
them to appear inside or outside the dental arch; or, 
as not infrequently happens, keeping them imprisoned 
within the maxillarv bones. 

Irregularities of individual teeth of the temporary 
set are rare. There may be a slight twisting or lappmg 




i'luuusion of the Anterior Teeth, caused by Loss 
pids and Molars. (Carabelli.) 

of the incisors, but no great deformity has been <3b- 
served. Most important irregularities occur in the 
permanent set; tlie superior central incisors may 
stand inside the dental arch, so that the inferior 
centrals close in front of them. Their crowns may be 
rotated either toward the median line or away from it, 
or may overlap each other. In the lower jaw the 
central incisors, owing to the frequent crowding of the 
lower anterior teeth, are often twisted or overlapped. 
The superior laterals are more frequetitly irregular 
than are the centrals. The most common irregularity 




Fia. 4737. — A V-shaped Upper Jaw. (From Kingsley's "Oral 
Deformities.") 

consists in the crown of the lateral overlapping that of 
the central. The laterals may be placed within 
the dental arch and held in that position by the 
interlocking of the lower teeth. Sometimes it happens 
that they are prevented from eruption by the canines, 
which have, by premature eruption, occupied their 
space. The inferior laterals are liable to irregularities 
siniilar to those described in connection with the in- 
ferior centrals; such irregularities produce, as a rule, 
no marked deformity, and are not usually of sufficient 
importance to be regulated. The superior canines are 

112 



very often in an abnormal position. The reason for 
this is not difficult to find, and has already been partly- 
explained. Erupting, as they do, subsequent to the 
lateral and first bicuspid, it often happens that the 
space necessary for their regular appearance in the 
dental arch has been encroached upon by the adjoining 
teeth. In consequence the canines must take a posi- 
tion either on the outside of the arch or within. Some- 
times the canine tckes a position alongside the central 
incisor; when this is the case, the displaced lateral is 
usually within the arch. A rotated canine is not un- 
"common, the rotation being toward the median 
line or away from it. The lower canines are 
seldom irregular. The upper first bicuspid also 
usually finds its normal place, on account of tlie 
period of its eruption and the fact that its crown 
is smaller than that of the first temporary molar 
which it supplants. 

The second upper bicuspid is much more fre- 
quently out of place than is the first. Though 
its crown takes up much less room than that of 
the second deciduous molar, which it replaces, 
still the teeth adjoining it (namely, the first bi- 
cuspid and first molar), being in position some 
time before the second bicuspid is ready to erupt, 
may encroach upon the space which should have 
been reserved for that tooth. Such a condition 
usually results from the too early extraction of 
the second deciduous molar. As a result of 
such extraction the neighboring teeth move to- 
gether, and sufficient room is not left for the 
free eruption of the second bicuspid, and that 
tooth in consequence, finding its way in the direc- 
tion of least resistance, is compelled to appear within 
or without the dental arch, as the case may be. The 
lower bicuspids are subject to irregularities similar to 
those of the upper bicuspids, although they occur 
less frequently. The first and second molars are 
rarely irregular in either jaw; each in turn being de- 
veloped behind teeth already in place, there is noth- 
ing to crowd them from their normal position. The 
third molar, on the contrary, has scanty room for 
eruption, and in consequence presents frequent irregu- 
larity. The lower third molar is often found with its 
crown presenting toward the posterior surface of the 
crown of the second molar. Sometimes it is tipped 




Fig. 473S.— a c! 
to erupt regularly i 
arch. (Salter.) 



ie in which the superior canines have not room 
L the arch, and are forced to appear within the 



forward so far that the force of occlusion and mastica- 
tion is borne upon its distal surface. This is the most 
usual form of irregularity, but the tooth may assume 
almost any position, even with the crown pointing 
backward toward the ramus of the jaw. The most 
frequent irregularity of the upper wisdom tooth is the 
turning of its crown outward or backward. 

Pathology in Size and Shape of the Teeth. — As a rule, 
the size of the teeth is in harmony with the proportions 
of the body. Giants have teeth which would be 
abnormally large if found in a person of ordinary size. 
The teeth of males are larger than those of females. 
When teeth are of unusual size, but proportioned to 
the size of the individual, they are normal for that 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



individual. There occur cases, liowever, in which 
certain teeth are entirely out of proportion to the 
alveolar arch. Such teeth may be roo large or too 
small. Upper central incisors, in rare instances, 
become a monstrosity in the excessive size of their 
cnnvns; the roots in such cases are not developed in 
similar proportion. 

The superior canines sometimes possess abnormally 
long roots, whose length may not be suspected till an 
attempt is made to extract them. Their extraction, 
on this account, is very difficult, or perhaps impossible. 
The molar teeth are sometimes abnormally developed, 
the crowns and roots alike being of unusual size. An 
abnormal diminution in the size of the teeth is not 




Fig. 4739. — A Pitting of the Enamel of the Six Anterior Teeth, 
due to Infantile Diseases Arresting the Process of Calcification of 
the Enamel. (Carabelli.) 

commonly found, except in the ca.se of the upper 
wisdom teeth, which are often quite small, no larger 
tlian a conical supernumerary tooth. Teeth which 
are pathological in shape are frequently observed. 
Their unusual shape may be due to a constitutional 
disturbance, occurring during their formative period, 
nr it may be due to a freak of nature — a cause un- 
known. Of the irregular shapes produced bj' a con- 
stitutional disturbance is to be noticed a pitting of the 
enamel of the six anterior teeth, and sometimes of 
the molars in either jaw. The pits may penetrate the 
entire surface of the enamel, or only a part of it. 
They may be irregularly disposed, or, as usually occurs, 
may be arranged in horizontal rows, of which there 
may be two or three in a single crown. Sometimes the 



•■■■;,:,• ■!»'■«• 



Fig. 474U — Shuwing the Effects of Hereditary .Syphilis on the 
Superior Incisors. (From Henry W. Williams. " Diagnosis and 
Treatment of the Diseases of the Eye.") 

pits are .stained a yellowish or yellowish-brown color. 
This irregular development is caused by some severe 
infantile disease occurring during the period in which 
the enamel of these teeth is being calcified, the process 
of calcification being thus interrupted. The adinin- 
i-tration of mercury in the early years of childhood 
has also been considered by .some to account for this 
irregularly formed enamel, but such a view is not now 
m'nerally accepted. 

.'\nother malformation due to a constitutional dis- 
turbance is that produced by inherited syphilis. The 
I'ffects of this disease upon the teeth are mo.st notably 
seen in the upper central incisors of the permanent set. 
The crowns of these teeth are stunted in size, are some- 
wh.at irregularly placed, and their cutting edges are 
narrower in width than are the necks of the teeth. The 
enamel on their cutting edges is imperfectly developed 

Vol. VIII.— 8 




and soon crumbles away, leaving crescentic notches. 
The upper laterals and canines, as well as the lower 
centrals, laterals, and canines, may be affected in a 
similar but less marked way. The first molars are 
usually imperfectly developed, and from 
a loss of enamel the corners of the teeth 
are rounded ofT, giving to the crowns a 
domelike appearance. As the character- 
istics of teeth affected by inherited syph- 
ilis were first described by Jonathan 
Hutchinson, it is common to call such 
teeth Hutchinsonian teeth. They are 
also called notched teeth, from the notch 
which may be found in the cutting edge 
of the six anterior teeth. This notch, 
however, is obliterated by wear, and thus 
in time becomes lost as a diagnostic sign. 
The term peg teeth in this connection is 
cfiminiinly used, and refers to the peglike 
appearance of the crowns of the anterior 
teeth. The peg shape does not become 
obliterated by wear, and always remains 
a diagnostic sign. While inherited syphilis does not 
aUvajs leave its mark upon the teeth, yet when the 
appearances described are present they are considered 
to be positive evidence of this disease. The tem- 
porary teeth are said by good authority to be some- 
times affected by hereditary syphilis, and to become 
nutclied and peg-shaped after the manner of the 
permanent teeth. 

Pathological shapes to be ascribed to a freak of 
nature are not commonly met with: still, a large 



Fiu. 4741. 
— .\ Case of 
Fusion of the 
Superior 
Central and 
Lateral Inci- 
sors. 



Fio. 4742.— A RiRht 
Superior Canine with 
an Abrupt Curve at the 
End of the Root. 



Fio. 4743. — A .Supe- 
rior Bicuspid with Three 
Uoots. 



number of such cases have been reported and flrawings 
made to illustrate them. .\s one of the more freiiuent 
irregularities maybe mentioned the fusion of adjacent 
teeth. There are two kinds of fusion: in one the 
tmion is accomplished by the cement of one root 
becoming increased and uniting itself to the cement of 
another root. In such cases each tooth has a separate 
pulp cavity and independent nourishment, the union 
being merely upon the outside and not affecting the 





Fio. 4744. — A Molar Fio. 4745. — A Molar 

Tooth with Five Roots. Tooth whose Roots are 
Fused into One, 

individuality of either tooth. The other kind of fusion 
consists in the union of the dentine as well as the 
cement, and a fusion of the pulp cavities into a single 
irregularly shaped space. Such teeth have a common 
and interdependent life. 

Fusion of this kind may be confined to the roots or 

113 



Teeth 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



include the crown as well, in which case a union occurs 
between the enamel of the two teeth. Fused teeth 
may be found in the temporary or in the permanent 
set and any teeth may be so affected. C.enerally the 
fusion is confined to two teeth. It is sometnnes un- 
susi)ected when involving only the roots, and the 
attempt to extract either of the fused teeth may result 
in its comiianion also being dislodged, or in a failure <o 
cxtnict either. The first form of fusion probably 
takes i)lace after the formation of the teeth, the 
latter while the teeth are in a developmental stage. 

There are irregular shapes not due to fusion, and 
which come under the head of miscellaneous forms. 
The incisors sometimes have their crown developed at 
right or obtuse angles with their roots, or have more 
than one root. The canines may have a twisted root, 
or one with a sharp bend occurring at the middle or 
upper end of its length. The bicuspids may have two 
or even three roots. In consequence of the tendency 
of the roots of the bicuspids to bifurcate, this occa- 
sional development of two distinct roots is to be 
expected. The upper and lower molars may have as 
many as five roots, or all their roots may be fused into 
one. 

Diseases of the Pulp. — Of the component tissues 
of the teeth the pulp is most subject to pathological 
changes. Normally this delicate and sensitive organ 
is well guarded by rigid walls, which not only protect 
it against external force, but also against the extreme 
thermal changes to which the oral cavity is exposed. 
So long, then, as the pulp remains thus protected, it 
is not subject to pathological changes; niorbid pro- 
cesses do not origin.ate in its tissue. It is true that 
there are writers who describe affections of the pulp 
independent of outside influences, but the genuineness 
of such cases has not been well established. In 
general the pulp is subject to pathological changes 
similar to those found in the soft tissue in other parts 
of the body; such peculiarities as are found are due to 
the existence of the pulp within a bony incasement. 
It must be borne in mind that the pulp is very vascular 
and very sentient; that the vessels and nerves are 
supported by a parenchyma of connective tissue, and 
that the whole organ is contained in an unyielding 
cavity whose only entrance and exit is a small foramen, 
whose calibre may not be larger than a bri.stle. 
Through this foramen the blood enters, and is in due 
time returned — a delicate piece of machinery capable 
of easily performing its duties when in natural adjust- 
ment, but impaired or destroyed when affected by 
force from without. Any agency which interferes 
with the protection which nature has thrown around 
the pulp IS calculated to set up morbid changes in its 
structure and interfere with its function. The most 
potent and frequent agency to be named is caries. 
When once this disease has located itself upon a tooth 
it usually progresses, unless checked by appropriate 
mechanical means, till a considerable portion of the 
enamel and dentine is destroyed and the pulp laid 
bare. Long, however, before the pulp is reached it has 
been subjected to conditions unfavorable to its healthy 
activity, and the chances are that when exposed by 
caries it is already in a pathological condition. 

An agency in producing disturbances of the pulp 
less important than caries is the natural wearing 
away of the substance of the teeth in the process of 
mastication. Such wear is usually without serious 
effect upon the pulp up to the period of middle life. 
Subsequent to that time, however, it may so deprive 
the pulp of its natural covering as to induce patholo- 
gical changes. 

A third outside agency, and one less frequently met 
with than the other two, is mechanical violence, in the 
form of a blow or fall, of such a nature as to sever the 
imion between the pulp and its blood and nerve sup- 
ply. Under such circumstances the pulp, as a rule, 
dies. There are, however, cases reported in which a 
sound tooth having been pushed out of its socket has 

114 



been replaced, and the pulp has apparently remained 
in a healthy condition. Such cases lend support to a 
supposition that a reunion is possible between the 
pulp and its blood and nerve supply; but this point 
ha« not vet been satisfactorily settled. 

Conijcxlion. — One of the commonest pathological 
affections of the pulp is congestion. A pulp examined 
in this condition shows increased redness, due to an 
increased flow of blood to the part and dilatation of 
the vessels. This condition is brought about through 
the vasomotor system, which responds to an irritation 
of the dentinal fibrils, which are in connection with the 
nerves of the pulp, and so with the general nervous sys- 
tem. Inasmuch as the normal pulp fills its cavity, an 
increased supply of blood must compress the tissue in 
the neighborhood of the vessels. The nerves share this 
compression, and hence the severe pain which is the 
usual accompaniment of a congested pulp. Caries of 
the tooth is the most common cause of congestion of 
the pulp. Through it a cavity in the direction of the 
pulp is produced which allows hot and cold drinks, 
food, and cold air to approach so near the pulp that 
they irritate it. Salt and sweet substances, also, if 
allowed to enter the cavity produced by the caries, will 
act upon the dentinal fibrils and irritate the pulp. A 
congested pulp is hypersensitive, giving pain upon the 
slightest occasion. A draught of cold water, the 
effect of which upon a normal pulp might be but a 
momentary twinge, would cause a congested pulp to 
ache violently. This ache is one of the more common 
kinds of toothache; it is violent, intermittent, throb- 
bing. It is very likely to be worse at night when the 
body is in a recumbent position. Congestion of the 
pulp does not necessarily result in a permanent 
pathological condition, provided the environment of 
the pulp can be so improved as to become normal, or 
nearly so. The normal environment may be restored 
by filling the cavity produced by caries, the pulp being 
thus removed from the near approach of heat or cold 
and irritating substances. The filling material should 
be a poor conductor of heat and cold, resembling in 
this respect, as far as possible, enamel and dentine. 
Guttapercha and oxyphosphate cement have proved 
the best substances with which to protect a congested 
pulp. It frequently happens that the pulp becomes 
congested in a tooth which contains a large metallic 
filling. The metal filling, being a good conductor of 
heat and cold, conveys injurious shocks deep into 
the dentine and unfavorably affects the pulp. Such 
a condition may be remedied by substituting a non- 
metallic filling for a metallic one. 

Inflammation. — While a congested- pulp may recover 
its normal condition, it frequently passes into astate of 
inflammation which may be either acute or chronic. In 
acute inflammation there succeeds to the active hyper- 
emia of congestion a stasis of blood in the inflamed por- 
tion; the vessels become dilated more than before, and 
often assume a tortuous course. The leucocytes can be 
seen leaving the capillaries and invading the surround- 
ing tissue. If the inflammation is purulent, pus cells 
and broken-down tissues become abundant. The 
affection may be local, confined to a small point which 
has been exposed by caries, or it may be general, 
involving the entire pulp. The organ is swollen, as in 
congestion, and pain results from pressure upon the 
nerve fibers. If the inflammation is very violent, it 
is likely to destroy the life of the pulp in a short time, 
through pressure upon the blood-vessels at the fora- 
men. The symptoms attending an inflammation of 
the pulp are similar to those of a congested pulp, but 
more severe. The pain is violent, throbbing, paroxys- 
mal, and is commonly known as a "jumping tooth- 
ache." The tooth is extremely sensitive to heat and 
cold, to sweet and salt substances, and to pressure 
within the cavity of decay. 

Such an acute inflammation may subside or pass 
into a chronic inflammation, the symptoms of which 
resemble those of the acute, but are of a less severe 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



Kiade. The cause of inflammation of the pulp is caries, 
which, as a rule, has penetrated to the pulp cavity and 
laid bare a minute portion of that organ, exposing it 
to the irritation of foreign bodies, thermal changes, 
:ind the secretions of the oral cavity. When suppura- 
tive inflammation occurs, the agency of bacteria is of 
interest, as it is well known that many varieties of 
these organisms exist in the mouth. Their approach 
to the pulp is made easy through the carious cavity, 
which lays bare the pulp, and the conditions are 
favorable for their activity. The course pursued by 
:iu inflammatory affection of the pulp depends largely 
un the extent to which its surface has been exposed 
t hrough caries. That there is always such an expos- 
ure in case of inflammation of tlie pulp cannot be 
affirmed, but that it does exist in the large majority 
of cases is attested by experience. If this exposure is 
small and allows no relief to the swollen condition of the 
organ, and no suflScient outlet to products of inflamma- 
tion, then an acute inflammation is likely rapidly to 
destroy the pulp, and transmit an inflammatory pro- 
cess along the root canals to the peridental membrane. 
If, however, the pulp has been freely exposed before an 
inflammation has been started up, then the inflamed 
pulp has a way of relief to its enlarged substance, 
and an exit for the products of inflammation. Such 
cases are more likely to assume a chronic form, inas- 
much as the life of the pulp is not immediately threat- 
ened. It is a matter of some chance, in the case of a 
pulp exposed by caries, just how soon an inflammatory 
affection will be started up, though no pulp when once 
exposed can long escape. If the cavity which exposes 
the pulp is hidden away in the back of the mouth, or 
protected by adjoining teeth, so that the pulp of the 
tooth is, in a measure, protected from alternations of 
temperature and severe contact with food, then the 
inflammatory affection may be delayed, and, when it 
does come, decay may have so opened the pulp cavity 
as greatly to modify the severity of the inflammation. 
» >n the other hand, when caries attacks the crown of 
the first molar and lays bare the pulp, it is immediately 
subject to severe irritation in the process of mastica- 
tion, and trouble begins at once. Inflammatory 
alTections of the pulp do not tend to recovery, but 
Konerally end in death of the pulp. This result may 
he, however, somewhat delayed by appropriate treat- 
ment. The exposed pulp may be capped over with 
iKinirritating, nonconducting material and thus 
siiielded. It is sometimes possible to prolong the life 
iif the pulp several years, provided the treatment is 
not long delayed after the beginning of the inflamma- 
tory aff'ection. After having been thus treated the 
I)ulp may give no further sensation of pain; it does 
not, however, often regain its normal condition when it 
has once passed through the inflammatory process. 

To alleviate the pain of a congested or inflamed pulp 
it is important, first, to determine which tooth is giving 
trouble. The testimony of patients cannot be relied 
upon to settle this point. They can usually indicate 
correctly the side upon which the affected tooth is 
located, but will often point to a perfectly sound tooth 
as the cause of tlieir pain. A thorough examination 
should be made, by the aid of the mouth mirror and a 
line exploring point, of all suspected teeth. If a tooth 
is found with a carious cavity of any considerable size, 
especially if the cavity is sensitive to the touch of an 
instrument, it is fair to infer that such a tooth is the 
line giving pain. The diagnosis can be confirmed by 
the application of a little cold water to the cavity of 
ilccay. Where a congested or inflamed pulp exists, 
tliis application will cause an exacerbation of the pain. 

Having located the tooth which is the seat of the 
difficulty, its carious cavity should be washed out with 
a syringeful of warm water, in order to remove irritat- 
ing particles of food. The next step is to make an 
application to the exposed pulp, or, if the pulp is not 
exposed, to the dentine in the neighborhood of the 
pulp, which will allay the pain. 



A simple and efficacious remedv is the oil of cloves. 
More powerful remedies are: phenol, ninety-five per 
cent.; creosote; a mixture of equal parts of oil of cloves 
and chloroform; a mixture of equal parts of oil of 
cloves and creosote. 

One drop of any of these remedies is usually suffi- 
cient for a single application. The medicine should be 
applied to the cavity on a pledget of cotton. Care 
should be taken not to press the cotton too tightly into 
the cavity, as it might thus become a mechanical 
irritant to an exposed pulp. In the use of concen- 
trated phenol, care should be taken to prevent its 
spreading to the adjoining gum and mucous membrane 
of the lips and cheek. 

It is very important, in treating toothache, to know 
whether the pulp in the affected tooth is alive or dead. 
If alive, it will respond to thermal changes and be .sen- 
sitive to exploration in the carious cavitv, and should 
be tre:ited as just described. If the pulp is dead the 
tooth is usually sore to percussion, and unaffected by 
applications of cold, though heat will sometimes be 
painful. 

It is not sensitive to the exploration of an instru- 
ment in the cavity of decay. The carious cavity of 
such a tooth should not be plugged with a dress'ing, 
but should be opened freely to give vent to the decom- 
posing pulp in the manner described in the section on 
affections of the peridental membrane. 

Abscess. — Closely allied to inflammation is abscess 
of the pulp. This affection, clinically, cannot always 
be distinguished from the preceding. Upon micro- 
scopic examination, however, it is possible to make 
out true abscess cavities. These may be deeply 
situated in the body of the pulp, or near "its surface. 

Gangrene. — Among the more advanced clianges in 
the pulp may be mentioned gangrene. This, as in 
other parts of the body, may be moist or drv. Gan- 
grene follows upon the sudden cutting off of the cir- 
culation from the pulp, as a result of acute inflamma- 
tions, or violence to the tooth of such a kind as to 
sever the artery at the apical foramen. A gangrenous 
pulp is of a grayish-green color, of slight consistence, 
and fetid odor. In such a pulp the normal structural 
elements become undistinguishable. In dry gan- 
grene the pulp contracts to a very small compass, and 
the part of the pulp cavity thus left vacant is occupied 
by a gas of decomposition. Gangrenous pulps, unless 
the pulp cavity is freely opened, produce severe in- 
flammation of the peridental membrane. 

Calcification. — .\nothcr group of changes embraces 
the various forms of calcification to which the pulp is 
subject. Among such may be mentioned the nodular 
form. In this variety small nodules of calcareous 
matter are sprinkled through the substance of the 
pulp, giving to it a gritty feel. The calcareous matter 
is similar in chemical composition to dentine, but does 
not have its characteristic structure. The calcareous 
nodules are located between the component parts of 
the pulp, and are not formed at their expense. This 
condition seems to be compatible with a healthy 
activity of the pulp, and apparently does not lead to 
serious consequences. Its etiology has not been 
explained. Another form of calcification exists, in 
which the new formation takes the place of the normal 
tissue of the pulp and is formed at its expense. The 
calcareous points are found scattered here and there 
through the pulp, usually in the coronal portion. 
The.se points become confluent till an aggregation is 
formed ranging in size from a grain of sand up to a 
mass sufficient to fill the entire pulp cavity, coronal 
and radical portion as well. This form of calcifica- 
tion does not take place when the tooth is in a normal 
condition, but seems to be induced either by the 
wearing down of the crowns of the teeth or by caries. 
In both cases the dentinal fibrils are subject to irri- 
tation, and this irritation determines the deposition of 
lime salts in the substance of the pulp. When once 
such a deposition begins, it tends to increase till the 

115 



REFEREN'CE HANDBOOK OF THE MEDICAL SCIENCES 



pulp is changed from a highly sensitive hving organ- 
Ksm to one practically lifeless, without nerves or 
vessels. During the course of calcification quite 
severe pain may arise, evidently due to the pressure 
of the calcareous masses upon the nerve filaments. 

Seconilarij Dniliiic.—A. change similar to that occur- 
ring in calcification of the pulp is that which takes place 
in the formation of secondary dentine. This formation 
is found on the periphery of the pulp at a place adja- 
cent to a carious cavity, and is deposited by the odon- 
toblastic laver of the pulp, which is the formative 
agent in no'rmal dentine. Secondary dentine is evi- 
dently a means taken by nature for the protection 
of the pulp against the injurious influences incident to 
advancing caries. Secondary dentine is similar in 
structure to normal dentine, containing, like it, 
tubules and fibrils. Its formation is, however, some- 
what less regular, and in case the secondary dentine 
extends far toward the interior of the pulp, it loses its 
supply of dentinal tubes and becomes less like dentine 
and more like a calcified pulp. While the formation of 
secondary dentine in the neighborhood of decay 
undoubtedlv tends for a time to prolong the life of the 
pulp, experience seems to show that secondary dentine, 
when once deposited, tends to increase to such pro- 
portions as in the end to destroy the life of the pulp. 

The process just described is to be distinguished 
from that deposition of dentine which takes place by 
degrees during the whole life of the tooth. This 
deposit is very slow in formation, and takes place 
uniformly around the inner side of the whole pulp 
cavity. By this physiological deposition of dentine 
the pulp cavities in the teeth of old people are reduced 
to very small proportions. This seems to indicate 
that tlie. pulp is useful and necessary inversely to the 
age of the tooth. 

Polypiis of the Pulp. — There is another pathological 
change which increases the size of the pulp. Such an 
increase can occur only in case the pulp has been 
exposed. Let such a pulp be subjected to the irrita- 
tion of foreign substances, and likewise to that of the 
sharp edges of a carious cavity, and it will sometimes 
proliferate and fill the cavity. 

Why the pulp does not become inflamed and de- 
stroyed under such circumstances cannot be explained. 
This process has usually been noticed in the case of 
young teeth. The grow-th may assume the size of a 
pea, or be larger. It is of fleshy consistence, and is 
organically united to the pulp by a narrow pedicle, 
hence it is called polypus of the pulp. In micro- 
scopic examination it is found to consist of numerous 
round and spindle-shaped cells, interspersed with 
fibrous tissue, and an epithelial covering has been 
described by some writers. Its blood-vessels pursue 
a tortuous and irregular course, unlike those in the 
pulp. No nerves have been found in this tumor, yet 
it is slightly sensitive to touch, resembling the gum in 
this respect. Sometimes a muco-purulent discharge 
issues from its periphery. A polypus protects the 
pulp against external violence. It is extremely te- 
nacious of life, and will grow again if cut off. 

A growth similar to a polypus takes place in some 
cases of fractured teeth. The pulp, having been 
exposed, proliferates through the openings caused by 
the fracture and forms a tumor outside the pulp 
cavity. This tumor, morphologically, resembles a 
true poh-pus of the pulp; it has, however, a nerve 
supply, and is quite sensitive to the touch, thus differ- 
ing from a polypus. Salter has named this growth a 
"sensitive sprouting of the pulp." 

Caries. — Under pathology of the dentine the most 
important process is caries. This process affects the 
enamel and cementum as well as the dentine, but has 
more to do with the dentine than with the other tis- 
sues. In the first place, it may be said that caries 
of the teeth does not resemble caries of bone. The 
term caries as applied to the teeth is a misnomer, 
given at a time when the true nature of the process 

116 



wa-s not understood. However, the term has become 
so generally used that is cannot now be easily dropped. 
The pathological change which occurs in caries is a 
decalcification and disintegration of the several tissues 
of the teeth. The latter condition follows very quickly 
upon the former, on account of the large proportion 
of earthy constituents existing in the parts attacked. 
Caries may affect any of the teeth of either dentition, 
but it affects certain teeth more frequently than 
others. Magitot has tabulated ten thousand cases of 
caries occurring in the permanent teeth, and his tables 
show that the tooth most liable to caries is the first 
lower molar, after which follow in succession the first 
upper molar, the second lower molar, first upper 
bicuspid, second upper bicuspid, upper lateral, second 
upper molar, upper central, second lower bicuspid, 
upper canine, first lower bicuspid, upper wisdom, 
lower wisdom, lower canine, lower central, and lateral. 
Caries not only shows a preference for certain teeth 
rather than for others, but it also shows a preference 
for certain parts of individual 
teeth rather than for other parts 
Those surfaces of the teeth v, hich 
are smooth and kept clean by tin 
motions of the tongue, lips, and 
cheeks, are not usually attacki 1 
by caries; while surfaces present- 
ing an uneven contour, abound- 
ing in pits and fissures, are its 
favorite seat. Hence, we find it 
located in the crowns of the molais 
and bicuspids, in the pits on the 
lingual surfaces of the six superior 
front teeth, and on all approxi- 
mal surfaces which, though not 
uneven, are not cleansed b^ the 
motions of the mouth. The buc- 
cal and labial surf aces of the teeth, 
just at the margin of the gum, are 
likewise often the seat of canes 
Caries manifests its presence bv a 
change of color in the tissues at- 
tacked. This change may be 
merely from translucency to opac- 
ity, or to a variety of colors 
ranging from yellow to brown, 
and even black; sometimes a gray 
or bluish-gray is seen. As a rule, 
the slower the progress of the dis- 
ease the deeper the color of the 
affected parts, and conversely, the 
more rapid its progress the lighter 
the color of the affected parts. 
Caries usually attacks the enamel 
first, though it may begin with 
the cementum. It starts in a small pit or fissure, on 
the grinding surfaces of the teeth, or on the approximal 
surfaces of the teeth. The enamel loses its peculiarly 
hard and dense surface. Instead of resisting the most 
highly tempered steel instruments, as does normal en- 
amel, it crumbles away under slight force. Thus a small 
opening is made through the enamel to the dentine. 
This opening may be as large as the head of a pin, or 
it may be very minute. During this process the 
enamel has become decalcified and disintegrated. 
Some authorities say that the center of the enamel 
prisms is first affected, and others that the inter- 
prismatic substance is first destroyed, in consequence 
of which the prisms separate and fall to pieces. When 
once caries has perforated the enamel it no longer con- 
fines itself to a narrow area, but spreads out laterally 
between the enamel and dentine. The degree of 
lateral extension varies greatly, but seems to be some- 
what dependent on the structure of the dentine. If 
the dentine is well calcified, and with few interglobular 
spaces, the lateral extension is not so great as when the 
dentine Ls imperfectly calcified and abounding in 
interglobular spaces. The carious process in its 




Fig. 4746.— An In- 
cisor Tooth ASected 
with Caries. a. A 
deposition of second- 
ary dentine about the 
cavity of decay. 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



lateral extension seems to follow the anastomoses of 
the dentinal tubules, which are very abundant at the 
junction of the dentine and enamel. After having 
affected a certain area on the periphery of the dentine, 
caries penetrates its substance, following the tubules 
toward the pulp. Inasmuch as the tubules converge 
from the periphery of the dentine toward the pulp 
cavity, the progress of caries is marked by a cone- 
.shaped area, the large end of the cone being in the 
jjeriphery of the dentine, and the small end pointing 
toward the pulp. Caries tends to penetrate the pulp 
cavity, and rarely fails, unless checked by mechanical 
means. When once the pulp cavity has been pene- 
trated, the pulp is exposed to the degenerative changes 
already described, and, as a rule, dies and disinte- 
grates. The carious process then invades the pulp 
cavity, meanwhile spreading laterally through the 
dentine from the area originally attacked, and disin- 
tegrating the enamel from the under side. By degrees 
the crown of the tooth becomes so hollowed out by the 
continuous softening and disintegration of the dentine 
that the shell of enamel left becomes unable to with- 
stand the force of mastication, and consequently is 




Fio. 4747. — Microscopic Section through a Carious Cavity Oc- 
curring in a Molar Tooth. A, The initial opening through the 
enamel; B, the cone-shaped area of decay — theaffected tissue being 
discolored and somewhat softened, but not disintegrated: C, a mi- 
nute pit in the enamel where caries has just started;!), theenamel; 
K, the dentine; F , the pulp cavity. 

broken away. Nor does caries stop with tha destruc- 
tion of the crown; it continues its work in the root, 
enlarging the root canal at the expense of the sur- 
rounding root substance until the root becomes a mere 
shell and is finally entirely disintegrated. _ The 
carious process in the root is not so rapid as in the 
crown, and roots may withstand its action for years. 

The microscopic examination of the carious process 
shows the change in color of the affected parts which 
has been described, and the disintegration of the en- 
amel rods. The tubules of the dentine appear enlarged 
in caliber; and their size increases as the process 
advances. The intertubular substance diminishes 
with the enlargement of the tubules, and finally 
(U.-;;ii)pears with the confluence of adjacent tubules. 
Microorganisms are found in great numbers within 
the tubules. 

In the cement, the carious process is similar to that 
foimd in the dentine. The lacuna- and canaliculi are 
enlarged at the expense of the surrounding tissue, 
which softens and breaks down as t he process advances. 

Microorganisms are present as in carious dentine. 

A chemical change to be especially noted in connec- 



tion with all the tissues affected by caries is the acid 
reaction which is invariably present. 

Elinlogy of Caries. — There are certain predisposing 
causes upon which all are agreed; of such may be 
mentioned a faulty calcification of the enamel, whicn 
leaves the dentine exposed; a faulty calcification of the 
dentine, which leaves it less able to resist degenerative 
changes; a crowded condition of the teeth, on account 
of which it is difficult to keep the spaces between the 
teeth clean. 

\yith regard to the exciting or immediate causes of 
caries, there has been great diversity of opinion. Of 
the ancient pathologists, some ascribed caries to a 
disturbance in the "humors of the body." Others 
regarded it as due to the ravages of worms which 
infested the oral cavity. 

When we come to observers of scientific repute, we 
find that the older ones held to a vital or inflammatory 
theory. According to them, the disease began from 
within, by an inflammatory process of the dentine or 
pulp, the process in dentine resembling caries of bone; 
hence the term caries was applied to it also. 

The vital theory of caries has been effectually dis- 
proved by the fact that when natural teeth have been 
mounted upon artificial plates, and thus worn in the 
mouth, they have been subjected to caries, precisely 
resembling the caries of the teeth normally situated in 
the jaw. 

By others, caries was considered to be a sort of 
gangrene, due to a disturbance in the nutrition of the 
dentine. 

When, however, the secretions of the mouth came to 
be studied with reference to their possible agency in 
producing caries, and when they were found to be at 
times acid, and when, also, the acid fermentations 
occurring in the mouth came to be studied in this 
connection, there was developed what is called the 
acid theory of caries. According to this theory, caries 
originates from without and not from within, as those 
holding the vital theory claimed. The active agency 
in producing it is acids, which are always present in the 
mouth, due either to acid secretions or acid fermenta- 
tions. These acids are to a large extent, it is true, 
neutralized by the alkalinity of the normal mixed 
saliva; but in some places, as in the crowns of molars 
and in the spaces between the teeth, the acid secretions 
are so protected from the neutralizing influence of the 
saliva that they are able to retain their reaction and 
attack the enamel, decomposing the phosphate of 
lime and other mineral constituents, of which it is 
largely composed. Having penetrated the enamel, 
the acids act in a similar manner upon the dentine. 
According to this theory the tissues of the tooth are 
affected by chemical decomposition, as if there were 
no vital element whatever concerned. To substan- 
tiate this view many experiments were made, by sub- 
jecting extracted teeth to the influence of a weak acid 
solution imitating conditions found in the mouth. 
Teeth thus treated underwent a softening and decalci- 
fication similar to that found in the mouth in the case 
of caries. The point was thus well established that 
caries consisted m the decalcification and disinteera- 
tion of the mineral constituents of the teeth by an 
acid. 

While some have held a vital theory to account for 
caries, and others an acid theory, still others again 
have taken middle ground and held a chemicovital 
theory. 

The discovery of the presence of microorganisms in 
the tubules of dentine affected by caries was an im- 
portant step in advancing our knowledge of the proc- 
ess. The name of Icptothrix buccalis was given to 
these organisms when first discovered. Though their 
true agency in caries was not at once understood, they 
were considered to play an important role. Extensive 
investigations have been made to determine more 
accuratelv the nature of the microorganisms found in 
the mouth, and their relation to the process of caries. 

117 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



The earliest of these investigations were conducted by 
Dr. W. D. Miller, of Berlin. His method was to infect 
sterilized culture media of vaiious kinds with neutral 
saliva or with neutral carious dentine, and he found, 
invariably, that, when the culture medium contains 
sugar, anacid is produced. By successive cultures he 
has isolated the organisms wliich produce the acid. 
Of the organisms he writes as follows: " We have, then, 
in carious dentine, two distinct fungi — one always, the 
other often, present; the former surely, the latter 
l)robablv, producing lactic acid from sugar" ("Ameri- 
can Sv.s'tom of Dentistry," vol. i., p. 803). Perfectly 
.sound dentine, subjected to a pure culture of the fungi 
just mentioned in a medium containing sugar, under- 
went, in course of time, typical caries. According to 
Dr. Miller — and his theory is now quite generally 
accepted — the history of caries is as follows: It starts 
wherever, from the contour of individual teeth or from 
the relation of one tooth to another, a collection of 
food is possible. In every such collection are multi- 
tudes of microorganisms which are capable of thriving 
in the presence of sugar, and of decomposing this sub- 
stance and forming lactic acid. This acid decalcifies 
the enamel and forms a small pit which, being con- 
stantly filled with food, offers a favorable nidus for the 
contiiiued growth of the same organisms. When the 
enamel has been penetrated, the organisms begin to 
multiply in the tubules of the dentine, and there con- 
tinue the decomposition of sugar absorbed from the 
mouth. The resulting lactic acid enlarges the tubules 
by the decomposition of the mineral constituents of 
the dentine. It is possible that at one time the secre- 
tions of the mouth may be more unfavorable to the 
life of microorganisms than at another, since it is well 
known that, at certain times and in certain individuals, 
caries progresses very rapidly. Dr. Miller's explana- 
tion of the phenomenon of caries is not considered 
complete, but it states the main factor in the produc- 
tion of caries, viz., the conversion of carbohydrate 
foods by the bacteria of the mouth into lactic acid and 
the dis.so!ution of tooth sub.stance by lactic acid. 
Bacteria are also, probably, responsible for the solu- 
tion of the organic material of the teeth. Very recent 
work upon the cause of dental caries has been done in 
the biochemical laboratory of Columbia University 
by Prof. William J. Gies and published in the journal 
of the .\llied Societies, vols, viii., ix., and x. 

Ernaion. — A condition resembling caries, and yet 
essentially differing from it, is erosion. Ero-sion is com- 
monly found on the labial surface of the six anterior 
teeth, either at the margin of the gum, or between it and 
the cutting edge. It also sometimes affects the bicus- 
pids and molars. Erosion produces shallow cavities, 
which involve the enamel and penetrate to the dentine. 
These cavities are larger at their external opening than 
in their deeper parts, and are smooth, hard, and polished 
throughout. They present neither the characteristic 
softening nor undermining growth which are found 
in caries. The cavities do not rapidly enlarge, but 
may becorrie of such size as to threaten" the life of the 
pulp. Caries is sometimes superadded to erosion, 
thus inodifying the course of the destructive process. 
The etiology of erosion is not definitely determined. 

Pathological Changes in the Cement. — The most 
common pathological change of the cement is an 
hypertrophy, which is due to an irritation of the peri- 
dental membrane. This membrane, lying between 
the cement of the root and the bony alveolus, is at 
once the formative membrane of the cement of the 
tooth and of the adjacent bone of the alveolus. When, 
however, the cement of the root has been completed, 
the activity of the peridental membrane, so far as its 
cement-forming function is concerned, normally ceases. 
It does not resume this function unless subjected to 
irritation, in which case it may deposit additional 
cement upon the root in various" ways. The deposit 
may be diffuse, covering the entire root, though most 
abundant at the apex. It may be nodular, the nod- 

118 




ules being found at any point on the root, and being of 
various sizes; or it may consist of a club-shaped en- 
largement at the end of the root. 

The added cement is similar in structure to the 
primary cement, the union between the two deposits 
being, as a rule, not noticeable. In certain cases, 
however, blood-vessels penetrate this secondary deposit 
of cement, a condition not found in the primary de- 
posit. Hj-pertrophy of the cement has never been 
observed in the case of the temporary teeth, and af- 
fects the permanent teeth during adult life. The 
teeth most commonly involved are the upper bicuspids 
and molars, though the others are not exempt. Hy- 
pertrophies of the cement are called hj^jercementoses, 
osteomata, and exostoses. Of the causes which pro- 
duce an irritation of the peridental membrane, and 
consequent h^-pertrophy of the cement, perhaps the 
most frequent is caries with its sequelse, viz., inflamma- 
tion and death of the pulp, with extension of the in- 
flammation to the peridental membrane. Another 
cause is the undue pressure which teeth are sometimes 
subjected to in the process of occlusion and mastica- 
tion. This arises when many of the teeth have been 
lost and the few remaining ones are compelled to 
bear all the strain of service. In such cases the peri- 
dental membrane is overworked, literally crowded to 
the wall, and in consequence may become irritated. 
The same effect may be produced by 
the insertion of fillings which project 
from the crown of a tooth so far as to 
concentrate the force of occlusion on 
the filled tooth. While hypertrophy 
of the cement is commonly due to irri- 
tation from undue force, there are cases 
in which teeth having no antagonists 
>are found to have hypertrophied ce- 
ment. The symptoms which may Fio. 4748. — 
arise from an hypertrophy of the ce- General Hyper- 
ment are caused by the pressure of the trophy of the 
new growth upon the nerves of the tT^R"' . "''?"' 
peridental membrane and upon the guperio? Molar 
nerves of the pulp at the apical fora- Tooth, 
men. Many cases of hj^pertrophy 
exist which occasion no symptoms, the condition be- 
coming known only after extraction. In old people 
it is usual to find the cement somewhat thickened, 
and this change can almost be called physiological, 
so constantly does it occur. Doubtless the process 
is so gradual that the surrounding tissues accom- 
modate themselves to the enlarged root, and their 
nerves are subjected to no irritation. In other cases 
pain is an important and persistent symptom. The 
pain may be localized and accompanied by a soreness 
in the socket, or it may be diffused throughout the 
jaw or reflected to adjoining parts of the head. Severe 
neuralgias of the head, face, and neck have been found 
to owe their origin to the hypertrophy of the cement 
of a tooth. The tooth may appear to be perfectly 
sound, in which case it is only possible to locate the 
source of the pain by means of the i-ray. When, 
however, neuralgias exist in connection with teeth 
which, though not carious, are the seat of pain or are 
sore in the socket, it is fair to suspect either an hyper- 
trophy of the cement or a calcification in the pulp. 
Not only does an enlarged cement cause severe neural- 
gic pains about the head and face, but cases of epi- 
lepsy and insanity have been reported as due to the 
.same cause. A case from Tomes' " Dental Surgery" is 
in point. "A lad, a farm laborer from Windsor, was 
admitted into the Middlesex Hospital for epilepsy. 
The usual remedies were tried for six weeks without 
effect. His mouth was then examined and the molar 
teeth of the lower jaw found to be much decayed, the 
fangs of some alone remaining. Although he did not 
complain of pain in the teeth or in the jaw, the decayed 
teeth were removed, and the fangs of each were found 
to be enlarged and bulbous from exostosis. During 
the eighteen months that succeeded the removal of the 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



diseased teeth he had not suffered from a single fit, 
though for many weeks previous to the operation he 
had had two or three per day." 

A second pathological change of the cement is 
absorption. This is often found in connection with 
hj-pertrophy, and occurs at scattered points and pro- 
duces depressions in the surface of the cement. In 
cases of long-continued inflammation about the apex 
of the root, the cement is likely to be in part absorbed, 
giving a rough outline to the apex. 

Pathology of the Peridental Membrane. — Disease of 
the peridental membrane may be due to a constitu- 
tional disturbance or to pathological affections of the 
pulp, or may be dependent upon, or associated with, 
calcareous deposits upon the root of the tooth. 
Of the constitutional affections which react upon the 
peridental membrane, Tomes enumerates rheuma- 
tism, syphilis, and the exhibition of mercury. 

Inflammation of the peridental membrane from 
rheumatism is independent of caries, and may involve 
one or more teeth. The inflammation is distributed 
over the entire membrane, causing a loosening of the 
tooth and a soreness in the socket. Its course is 
subacute or chronic, does not tend to abscess, and is 
amenable to constitutional treatment. 

Inflammation of the peridental membrane from 
syphilis is chronic. Pus may be discharged around 
the neck of the tooth, which becomes sore in the socket 
and loose. If the disease is unchecked the teeth may 
fall out of their own accord, owing to a complete de- 
struction of the peridental membrane. Associated 
with this process there often occurs a necrosis of the 
surrounding bone. 

Inflammation from the administration of mercury, 
whether in the treatment of syphilis or not, is associ- 
ated with ptyalism, and is of a subacute or chronic 
character. The teeth become loosened and sore in 
their sockets, and, if the drug is long continued, a 
discharge of pus around the neck of the teeth and final 
loss of the teeth may result. 

The effect of phosphorus upon the peridental mem- 
brane, though not belonging strictly under constitu- 
tional affections, is of great interest. Persons subjec- 
ted to the fumes of phosphorus, as are those who work 
in match factories, often have necrosis of the maxillary 
bones. This necrosis starts with an inflammation of 
the peridental membrane, which Is very sensitive to 
the irritating fumes of phosphorus. As a result of 
inflammation the membrane is destroyed, and the 
bony alveolus being thus cut off in large degree from 
its source of nourishment, necrosis is invited. It has 
been found that this disease mainly affects operatives 
in whose mouth are carious teeth, or who have had 
teeth extracted while pursuing their occupation. 
The phosphorus fumes enter a carious cavity and reach 
the peridental membrane by way of the apical fora- 
men. If, however, the teeth are sound and the gums 
healthy, phosphorus has little if any destructive effect 
in the mouth. 

Pathological affections of the peridental membrane 
consequent upon disease of the pulp are of frequent 
occurrence. When the pulp has become severely 
inflamed it is common to find, in addition to the symp- 
toms attendant upon simple inflammation of the pulp, 
a soreness of the tooth in the socket. If the tooth is 
then percussed with a steel instrument the patient 
will flinch. This is an indication that the inflamma- 
tion has proceeded up the root canal and extended to 
the peridental membrane situated around the apex of 
the root. Symptoms pointing to inflammation around 
the root do "not always appear during the inflamma- 
tory stage of the pulp; they more commonly follow its 
death and putrefaction. When this has occurred, 
irritating products of decomposition, both gaseous and 
liquid, pa.ss up through the canal and set up acute 
inflammation in the membrane at the apex of the root. 
In the light of our knowledge of the agency of micro- 
organisms in inflammatory processes, we must consider 



that the bacteria which were active in producing 
inflammation of the pulp, are akso active in the conse- 
quent mflamraation of the peridental membrane. 
This membrane being of connective tissue, and richly 
supplied with blood-vessels, is an excellent field for in- 
flammatory action, and being closelv confined between 
unyielding walls, and having an abundant ner\-e sup- 
ply, is capable of producing symptoms of the severest 
character. When an inflammatory process has 
started at the apex of the root, the tissues become 
swelled and engorged with blood, the condition ex- 
tending from the apex toward the neck of the tooth. 
In consequence of the swelling of the membrane, the 
tooth is pushed slightly from its socket and becomes 
loose. The clinical symptoms are u.shered in bv a dull, 
continuous pain, which is not occasioned bv changes 
of temperature, as is often the case with inflammation 
of the pulp. The tooth upon pressure feels sore in the 
socket, yet during the first stages of the inflammation 
a grinding of the affected tooth against its antagonists 
gives some relief. The inflammatory process some- 
times stops at this point, but very often goes on to the 
formation of an alveolar abscess. 

Alveolar abscess forms about the tip of the root. 
As pus collects, the neighboring bony tissue is ab- 
sorbed, and a cavity is formed varying in size accord- 
ing to the severity of the inflammation. Like 
abscesses in other parts of the body, it seeks an outlet 
at- the point of least resistance. There are several 
ways in which the pus may 
make its escape. It may pene- 
trate the bony alveolus in a line 
which is, roughly speaking, at a 
right angle to the root of the 
affected tooth, and thus make 
its escape into the mouth, or, in 
some cases, upon the face. Or 
it may pass down the length of 
the root, eit her between t he peri- 
dental membrane and the ce- 
ment, or between the peridental 
membrane and the bony socket, 
in both cases discharging about 
the neck of the tooth. When 
an alveolar abscess occurs in 
connection with the six an- 
terior teeth and bicuspids of 
the upper jaw, it usually discharges on the labial surface 
of the alveolus, at a point about opposite the tip of the 
root of the affected tooth. In rare instances an abscess 
connected with these teeth may discharge on the out- 
side of the front part of the face or into the luisal cavity, 
and in the case of the bicuspids, into the antrum of 
Highmore. An abscess occurring in connection with 
the upper molars most commonly discharges on the 
buccal surface of the alveolus, about opposite the tips 
of the roots affected. It may, however, discharge m 
the neighborhood of the hard palate, when proceeding 
from the palatal root. Besides these usual points of 
discharge, the abscess may open into the antrum or 
upon the outside of the face, near the union of the 
malar and superior maxillary bone. Abscesses 
formed about the lower anterior teeth usually open on 
the labial side of the alveolus, within the mouth. 
They may, however, open on the outside of the face, 
below the horizontal portion of the jaw. .Xbsccsses 
in connection with the lower bicuspids usually open 
on the buccal side of the alveolus, though they may 
discharge on the face, along the body of the jaw. 
Abscesses connected with the lower molar teeth usu- 
ally find exit upon the buccal side of the alveolus, but 
sometimes on the outside of the face, adjoining the 
inferior maxillary bone. Cases are reported in which 
the abscess has opened in the neck, and even as low 
down as the infraclavicular region. .\lveolar ab- 
scesses usually assume a chronic condition, and keep 
up a discharge of pus from their fistulous opening as 
long as the root in connection with which they have 

119 




Fig, 474y. — Absorp- 
tion of Bone, produced by 
an Alveolar Abscesa at 
the Tip of the Hoot of a 
Left Superior Incisor. 



REFERENCE HANDBOOK OF THE MEDIC.IL SCIENCES 



been formed remains in the mouth, or until the pulp 
canal of the root has been jiroperly cleaned and filled. 
The opening of an alveolar abscess upon the face or 
neck has oftentimes been mistaken for the discharge 
from necrosed bone. A case coming under the obser- 
vation of the writer, while in charge of the Dental 
Infirmary of the Harvard Dental School, will illus- 
trate the point. A farmer, from the western part of 
Massachusetts, came to the Massachusetts General 
Hospital to be treated for a fistula opening at the 
symphysis of the lower jaw. The fistula discharged 
more or less, and was thought to be due to necrosis of 
the lower jaw. The condition had existed for about 
two years, and had been treated by injecting the 
fistula with various medicaments. At the hosi)ital 
they declined to operate till his teeth had been 
examined. Such an examination showed a lower 
incisor wliich, though not carious, was believed to 
contain a dead pulp and to be the origin of the fistula. 
The tooth was extracted at the Dental Infirmary, and 
the patient .idvised to return home and report in a 
month's time. In due time the patient reported that 
the fistula had completely healed. While not all 
cases of fistula about the face are due to dental 
abscess, yet the teeth should always be examined 
when such a case presents itself. 

The clinical symptoms attendant upon alveolar 
abscess are well marked and of peculiar severity. 
Since alveolar abscess starts with simple inflammation 
of the peridental membrane, the first symptoms are 
the same as those described under that affection. 
As tlie condition advances, however, the pain becomes 
more intense, the tooth is farther protruded from its 
socket, and is exquisitely .sensitive, the touch of a 
finger often being sufiicicnt to produce great agony. 
Sometimes the formation of pus is marked by a chill 
and rise of temperature. This formative stage may 
last from twenty-four to forty-eight hours; meanwhile 
the pus has been working its way through the sur- 
rounding bone into the soft parts. When this has 
occurred the face in the neighborhood of the affected 
tooth becomes swollen, and there is a marked remis- 
sion of pain. The mucous membrane of the gum 
about the alveolar abscess is much congested and 
swollen, besides being sore to the touch. 

As peridental inflammation and alveolar abscess are 
very common causes of toothache, it is necessary to 
distinguish between the toothache so caused and that 
due to irritation of the pulp. Toothache from irrita- 
tion of the jiulp is started by the pressure of food 
against the pulp, by a sudden variation of temperature, 
or by sweet or salty substances. The pain is violent, 
but intermittent, and no soreness of the tooth in the 
socket, as a rule, exists. Toothache from inflamma- 
tion of the peridental membrane or alveolar abscess is 
started by the death and decomposition of the pulp. 
The pain is continuous; it is increased by the applica- 
tion of heat, diminished by the application of cold. 
The tooth is sore in the socket, and if the crown is 
tapped with an instrument the patient will flinch. 
The tooth is protruded from the socket, the gums are 
inflamed, and the face is swollen. 

The treatment of peridental inflammation or alveo- 
lar abscess is, first, to remove the cause of the irrita- 
tion. If the tooth is without value to the individual 
it should be extracted. This is the quickest way out 
of the difficulty. If, however, it is desirable to pre- 
serve the tooth, its pulp cavity should be at once 
opened and cleansed from all decomposing material. 
It this is done in the first stage of the difficulty it is 
usually siifficient, and, the source of irritation being 
removed, the inflammation subsides. If the case be 
one of alveolar abscess the cleansing of the pulp 
cavity is of advantage, not only in removing the 
source of irritation, but also in giving a vent to the 
forming abscess through the root canal. In many 
cases, however, the abscess will open through the 
alveolus in spite of treatment. Such an opening can 

120 



sometimes be hastened by incising with the lance over 
the affected root. Whether pus can be reached with 
the lance or not, the incising of the gum gives relief by 
diminishing the congestion of the part. The use of 
leeches upon the gum is an old and often effective rem- 
edy. The tincture of iodine painted upon the gum is 
of common use; also the application of capsicum 




Fio. 4750. — A Vertical Section through a Lower Incisor and 
Surrounding Parts, Illustrating two Ways in which an Alveolar 
.abscess may find Vent. The first, and more common way, is 
by the fistula opening at c; the second, and less common way, is 
by the fistula opening at c'. a, the tongue: b, the lower lip; d, the 
abscess cavity; e, the inferior maxillary bone. 

plasters, slippery-elm poultices, and roasted raisins. 
A poultice should never be applied to the outside of 
the face, on account of the danger of causing the 
abscess to discharge externally and leave a scar upon 
the face which is a permanent disfiguration. 

During recent years much attention has been given 
to the condition of the bonj' alveolus around the ends 




Via. 4751.— .V-ray Showing Pathological Condition about the 
Root of a Superior Central Incisor. Such an area may produce 
serious secondary infection and calls for the extraction of the 
tooth involved and curetting of the adjacent bone area. 

of the roots of the teeth. Where an inflammatory 
condition has existed it is very common to find by the 
i-ray an area of absorption. A bacteriological ex- 
amination of this area discloses bacteria which may 
be carried to remote parts of the body and produce 
secondary infection. For this reason great care 
should be taken to x-ray pulpless teeth and determine 
whether the periapical area is healthy or not. If it 
shows a pathological area, the tootli should be ex- 



REFEREN'CE HANDBOOK OF THE MEDICAL SCIENCES 



tracted and the bone curetted. In some cases the 
tips of the roots can be amputated in situ and the 
tooth saved for further usefulness. It has been 
clearly shown that rheumatism and serious affections 
of the heart and other organs can be traced to pus 
foci developed about the apices of teeth as a sequence 
to the death of the pulp. 

Calcareous Deposits on the Teeth. — Calcareous de- 
posits are of two classes: those originating from 
the saliva, and called salivary tartar or salivary 
calculus, and those originating apparently from "a 
serous exudation from the peridental membrane, 
and called serumal calculus. The salivary tartar 
or calculus is composed mainly of phosphate of 
calcium, which is contained in the saliva and is pre- 
cipitated upon the teeth. It is found in groatost 
abundance on the buccal sides of the upper first 
molars, near the opening of the parotid gland, and on 
the lingual side of the lower anterior teeth, near the 
opening of the submaxillary and sublingual glands. 
Salivary calculus is first deposited at the neck of a 
tooth, and, if not removed, spreads both toward the 
cutting edge and in the opposite direction up the root. 
In its progress along the root it presses away the gum 
from the neck of the tooth and separates the peridental 
membrane from its attachment to the cement. If 
allowed to rest in contact with the peridental mem- 
brane, it destroys its life, and also that of the adjacent 
bony alveolus, thus largely diminishing the natural 
support of the tooth. In this way the teeth afTectcrl 
become loosened, and may be entirely dislodged. 
Salivary calculus, though, as a rule, limited to the 
regions described, may in much neglected mouths 
cover the entire lingual side of the lower teeth and the 
buccal sides of the upper teeth. The treatment of 
this deposit consists in its removal, after which the 
peridental membrane quickly resumes its normal 
character, except such portions as have been de- 
stroved, and the gum closes around the neck of the 
tooth. 

The second form of calcareous deposit, called the se- 
rumal, has nothing to do with the saliva, nor Ls it 
limited to certain localities in the mouth. It is sup- 
posed to be due to a deposition from serum exuded 
from the gingival margin of the gum and peridental 
membrane; this deposition taking place in conse- 
quence of irritation. It may affect any of the teeth, 
and is located at the margin of the gum, often hidden 
from sight. In color it varies from yellow to brown, 
and even black. It often encircles the root of the 
tooth, but may be deposited in patches. It increases 
slowly but is destructive to the peridental membrane, 
which becomes separated from the root. The al- 
veolar bony processes about the neck of the tooth 
are in time absorbed, and the natural support of 
the tooth is diminished. 

In connection with this deposit there may be a flow 
of pus, due to irritation of the peridental membrane. 
To this condition the name pyorrhea alveolaris has 
been given. While salivary calculus causes flic loosen- 
ing and falling out of the lower front teeth, the serumal 
deposit may effect the loosening and falling out of any 
of the teeth, and is the most common cause of that 
result. 

There remains to be described an affection of the 
peridental membrane which is very destructive to 
that tissue. It is usually associated with a deposit of 
serumal calculus, and may be very similar to the 
affection just described. The calcareous deposits are, 
however, more likely to be in patches, and to advance 
more rapidly to the apex of the root. By this means 
pockets are formed along the side of the root, due to 
a separation of the peridental membrane from the 
cement of the root. In the first form of serumal 
deposit the peridental membrane is separated from 
the tooth around the entire circumference of the root, 
and from its neck as far up as the dejiosit reaches; 
the tips of the root meanwhile being firmly attached 



to the peridental membrane until the tooth falls out. 
In the second form, however, the root may be sepa- 
rated from its peridental membrane on one side up 
to its apex, and in other parts firmly attached. At 
the apex the root is often entirely separated from its 
surrounding membrane, though at its neck there may 
be a fairly good union. This form of calculus is 
associated with a flow of pus and rapid destruction of 
the peridental membrane. This membrane having 
been destroyed, the tooth loses its hold in the socket, 
and in time drops out. There is some reason to sup- 
pose that this disease is due to a special microor- 
ganism, and that it is infectious. On this account it 
has been called infectious pericementitis. The term 
]>yorrhea alveolaris Ls commonly applied to this as 
to the preceding condition. The treatment of both 
kinds of serumal calculus with associated inflamma- 
tion of the peridental membrane is to remove the 
deposits of calculus and to keep them removed. To 
lliis must be added tliorough cleanliness of the teeth, 
and a washing out of all pockets produced by the 
separation of the root from its membrane. The use 
of antiseptic and astringent fluids in such pockets Ls 
a desirable and effective treatment, especially in that 
form of deposit last described. In people of middle or 
afivanced life calcareous deposits are more destructive 
to the teeth than is caries. 

Extraction of the Teeth. — The extraction of the 
teeth may be called for by various conditions, of 
which the more common are: 

1. A crowded condition of the teeth which threatens 
or has caused irregularity. The extraction of teeth to 
correct irregularities Ls seldom resorterl to at the 
present time. It is considered better to enlarge the 
dental arch and make room for irregular teeth rather 
than extract them. 

2. The existence of a few teeth in the mo\ith which 
interfere with the adju.stment of an artificial plate. 
This is a very common cause for extraction, inasmuch 
as a more satisfactory plate can, as a rule, be made for 
a mouth having no teeth than for one having a few 
scattered teeth. 

3. The existence of pain due to: (a) Congestion or 
inflammation of the tooth pulp; (6) inflammation of 
the peridental membrane; (c) alevolar abscess. 

More teeth are extracted to relieve pain than for 
any other cause. Where teeth, however, by treat- 
ment can be relieved of i)ain and made useful organs, 
they should not be extracted. 

4. The existence of dLseased conditions of the 
tissues in the neighborhood of the teeth. Pus foci at 
the tips of roots in most cases can only be cured by 
extraction. All pulpless teeth should be j-rayed and, 
if inflammatory areas are found about their apices, 
they should, as a rule, be extracted. In some cases 
their inflammatory areas can be treated by amputa- 
tion of the tip of the root and curetting affected bone 
area. Much rheumatism and also serious affections 
of important organs of the body are caused by pus 
foci about the tips of roots. 

An inflammation of the antrum is sometimes best 
treated by extracting an upper first molar or second 
bicuspid and making an oi)cning through the end of 
the root socket into the ant nun. By this process the 
antrum can be thoroughly cleansed and good drainage 
established. There are tumors of the jaw, and ca.ses of 
caries or necrosLs of the maxillary bones, which 
necessitate a removal of teeth. 

5. The persistence of the tcmiiorary teeth when the 
permanent teeth are about to erupt. 

It may be laid down, as a rule, that the temporary 
teeth should not be removed until the permanent 
teeth are ready to take their place. When this condi- 
tion exists, the roots of the temporary teeth have been 
for the most part absorbed, and the crowns have 
become loose. While the above rule should be 
adhered to as far as possible, yet there are cases in 

121 



REFERENCE HANDBOOK OF THE ]MEDIC.\L SCIENCES 



which severe inflammation connected with the tem- 
porary teeth requires their premature extraction. 

The Process of Extraction. — The process may be 
divided into three stages: (1) Seizing the tooth witli 
the forceps. (2) Loosening its connection with its 
surroundings. (3) Removing the tooth from its 
socket. 

The process of extraction and the instruments em- 
jiloyed varv greatlv with tlie different teeth in the 
mouth, a" knowledge of tlic number, shape, and size 
of the roots of the teeth is necessary to insure success 
in their removal. To extract the teeth of tlio upper 
jaw, the patient should be placed with the head t hrown 
well back, and the operator should stand at the 
])atient's right side. With the left hand the lips and 
cheeks should be retracted and the upper jaw firmly 
grasped. 

The upper central incisors are extracted with a for- 
ceps whose beaks are made to adapt themselves to the 
nearly conical neck of this tooth. The forceps should 
be applied with one beak at the labial surface of the 
neck of the tooth, and the other at the lingual surface. 
The beak of the forceps should be carried well up be- 
tween the margin of the gum and the root of the tooth. 
When the tooth has been thus grasped, it should be 
gently but firmly rotated, in order to loosen it from its 
socket. A forward-and-back motion may with ad- 
\-antage be combined with the rotatory motion. When 
the tooth is felt to have been loosened, it should be 
removed by a steady pull in the direction of its long 
axis. 

The superior lateral incisors are extracted in a man- 
ner similar to that of the central incisors, and with the 
same forceps. Inasmuch as their roots are somewhat 
compressed laterally, the rotary motion is not so 
important as with the central incisors. 

The superior canines are quite difficult to extract, 
owing to their very long roots. The upper incisor 
forceps are usually employed for the canines. The 
tooth should be grasped as high up on the root as 
possible. To loosen the tooth from its socket the 
rotary motion must be combined with the forward- 
and-back motion. When loose, a straight pull in the 
line of its long axis is necessary for its removal. It 
must be borne in mind that the root of the canine is 
decidedly flattened on its sides, and therefore offers 
considerable resistance to rotation. 

The upper bicuspids may be extracted with the 
upper incisor forceps; or they may be conveniently 
extracted with the alveolar bayonet-shaped forceps. 
The upper bicuspids should be grasped well up on the 
root and loosened by a side-to-side motion. Their 
roots being long and slender, great care is required to 
prevent flieir fracture. If the first upper bicuspid 
has a bifurcated root, it is often impossible to re- 
move the tooth without breaking off the tip of one of 
the roots. 

The first and second upper molars are extracted by a 
forceps whose inner beak is fashioned with a single 
concavity, it is thus fitted to embrace the inner buccal 
root of the first or second upper molar. The outer 
beak is divided by a longitudinal ridge into two con- 
cavities, while the tip of the beak is pointed in the 
middle. It is so made in order to embrace the two 
buccal roots of the first and second upper molars, and 
to conform to the depression between these roots. 
These forceps should be grasped in the palm of the 
hand, the thumb being brought into position between 
the angle formed by the two handles and the joint. 
The third and fourth fingers should be closed over the 
curve of the left handle. Owing to the divergence of 
the three roots of the upper first and second molars, 
considerable loosening is necessary before they can be 
extracted. This is effected by a"side-to-side"motion; 
as the outer alveolar plate is thinner than the inner, 
the main force should be applied in an outward direc- 
tion. When the tooth is thoroughly loose in its socket, 
it can be removed by a downward and outward motion. 

122 



Upper wisdom teeth are not usually difficult to ex- 
tract, as their roots are commonly fused together. 
In order to loosen them they should be turned firmly 
outward. By this movement their attachment to the 
socket can be readilj' broken up and the tooth removed. 

In case the crowns of the upper teeth are badly de- 
cayed or entirely lost, the alveolar or root forceps 
should iDe used. With this instrument any root of the 
upper jaw can be extracted ; the rules for the extraction 
of roots being substantially the same as those for teeth 
with crowns. It is necessary, however, to carry the 
blades farther up into the alveolus than when the 
crown is present. Great care should be taken not to 
crush the root by too firm a grasp. With the first and 
second upper molars it often happens that the three 
roots must be extracted separately. 

In extracting the inferior teeth the patient should be 
situated much lower down than for extracting the 
superior teeth. The operator should stand at the 
patient's right side, oftentimes well to the back. The 
lower jaw should be grasped by the left hand, and 
supported from beneath by the palm and last three 
fingers, while the thumb and forefinger are placed j 
within the mouth to retract the lips and tongue from 
the tooth to be operated on. The lower incisors, 
owing to the lateral compression of their roots, can- 
not be rotated in the process of loosening them. 
This must be accomplished by a forward-and-back 
movement. 

The lower canines, owing to their very long roots, 
are often quite difficult to extract. They are to be 
loosened by a forward-and-back movement, to which 
a slight rotary motion may be added. When loose, 
they are removed by being pulled straight up from the 
socket. 

The lower bicuspids should be grasped well down 
upon the root and loosened by an in-and-out motion. 
The alveolar plate being much thinner on the outer 
than on the inner side, it will yield more readily out- 
ward. When loosened, the lower bicuspids are re- 
moved by being pulled straight up from the socket. 

The lower molars are extracted by a forceps whose 
beaks are divided by a median ridge, and are termi- 
nated by a pointed tip ; it is thus able to embrace the 
two roots of the lower molars, and to engage the de- 
pression between them. To extract the lower first 
and second molar teeth, they should be rocked from 
within outward till loose, using more force when 
turning them outward then in the opposite direction. 
When loose, they may be removed by an upward-and- 
outward pull. The lower third molar often gives 
great difficulty in extraction, owing to the curve of 
its roots, which hook backward toward the ramus of 
the jaw. It must be loosened by a side-to-side rock- 
ing. Owing to the backward curve of its roots it can- 
not be lifted from its socket by a force exerted directly 
upward. 

Elevators are often useful; they are straight and 
curved levers, with which a tooth is pried out of its 
socket, a neighboring tooth being used as a fulcrum. 

The extraction of the temporary teeth is performed 
after the same manner as that of the permanent teeth. 
The operation is, however, much simpler, especially if 
performed at a time when the teeth are about to be 
shed by nature. In the premature extraction of the 
temporary molars there is always the possibility of 
bringing away the crown of the developing bicuspid, 
which is located between the roots of the molar tooth. 
Diminutive forceps are made for the temporary teeth, 
but temporary teeth can be readily extracted" by the 
root forceps made for the permanent teeth. 

Acddents^ of Extraction. — In the extraction of the 
teeth certain accidents may occur; they may be un- 
avoidable or due to unskilfulness or carelessness. The 
following are the more common : 

Fracture of the tooth often happens, and is due 
usually to an excess of force, or to misdirected force, or 
to an insufficient grip upon the tooth. Cases occur. 



REFERENX-E HANDBOOK OF THE MEDICAL SCIENCES 



Tendons, Injurlrs and 
Dl!iea.<«e8 of 



however, in which fracture of the tooth is unavoid- 
able; this is especially the case when the roots are 
misshapen and locked into the jawbone. When the 
tips of roots are, as the result of fracture, left in the 
maxillary bones, it is not always wise to remove them. 
Nature will usually expel them in due time. 

Fracture of the alveolus occurs, to a limited extent, 
in every tooth extraction, and produces, as a rule, no 
troublesome symptoms. By unskilfulness, however, 
a large portion of the alveolus surrounding a t«oth may 
be crushed or fractured, and necrosis sometimes ensues. 

Fracture of the jaw may result from tooth extrac- 
tion. The fracture may be in the upper jaw, or in the 
body of the lower jaw. It maj- or maj' not imply fault 
on the part of the operator. 

Dislocation of the lower jaw usually happens with 
people whose jaws are loosely hung, and are in the 
habit of slipping out of the socket. If this tendency 
is known to exist, it is well to apply a roller bandage 
over the head and under the jaw before operating. 

Removal of the wrong tooth Ls an accident which 
happens, as a rule, only to inexperienced or careless 
operators. 

Removal of two or more teeth instead of one may 
happen from an h>-pertrophy of the cement uniting 
adjoining roots below the gum. It may happen when 
the tooth to be extracted is overlapped by an adjoining 
tooth. It may happen also by the slipping of an ex- 
tracting instrument, whereby a loose tooth is knocked 
out. 

Laceration of the mucous membrane of the gum 
occurs to a limited extent in every extraction, but, 
through carelessness or unskilfulness, may be verj- 
extensive. 

Falling of the Tooth into the Esophagus or Air Pas- 
sages. — A tooth will sometimes escape from the grasp 
of the forceps and be swallowed. From thLs accident no 
serious results are to be expected. Cases are now and 
then reported in which a tooth falls into the larynx. 
This constitutes the most serious accident that can 
attend extraction. Such a tooth may be coughed up 
from the larj-nx, or it may enter the bronchial tubes, 
causing s\-mptoms which are always serious and often 
fatal. 

The inferior dental nerve has been crushed in the 
extraction of the lower wisdom teeth. In such cases 
a loss of sensation has occurred in the lower part of the 
face. Usually thLs passes away, though it may be 
permanent. In attempting to extract the roots of 
the upper bicuspids and molars they have been pushed 
into the antrum. When this happens, the opening 
into the antrum should be enlarged and the roots 
removed. 

Hemorrhage after extraction is usually moderate in 
amount and of short duration. Such cases require no 
treatment. There are cases, however, in which the 
hemorrhage is so prolonged as to produce alarming 
sjTnptoms, and in rare instances death has resulted. 
Great care should be taken in dealing with people 
having the hemorrhagic diathesis. To control hem- 
orrhage after extraction the most successful method is 
to apply pressure to the bleeding parts. The bleeding 
usually takes place from the socket of the extracted 
tooth. The socket should be packed with cotton, lint, 
sponge, or any soft unirritating material. After 
packing the socket a compress of soft material, cover- 
ing the socket and surrounding parts, should be super- 
added. Upon this compress a gentle pressure should 
be maintained, either by the fingers or by the opposing 
jaw. An effective method of applying pressure after 
the socket has once been plugged is to soft«n a piece of 
gutta-percha in hot water and mould it to the affected 
region. Enough gutta-percha should be used .so that 
the opposing teeth or alveolus can be embedded in it 
by the closing of the jaws. Let the jaws be closed and 
a roller bandage passed over the head and under the 
chin, and firm and constant pressure is secured upon 
the bleeding area. In severe cases care should be 



taken to keep the head upright and the extremities 
artificially warmed. .\s st\jitics can be mentioned 
perchloride of iron, tannic acid, and preparations of the 
suprarenal capsule. Of these, perchlorifle of iron is 
the least valuable. Tannic acid is a reliable agent; the 
powder may be applied to the so<ket on a pledget of 
cotton. Preparations of the suprarenal capsule are 
especialh- valuable in arresting dental hemorrhage. 
St>-ptics can be used with advantage in connection 
with the use of pressure, as described above. Very 
severe eases of hemorrhage have been controlled by 
the use of the actual cautery. If this be u.sed, it 
should not touch the parts, "but be held just near 
enough to bake them. If the cauterj- touches the 
tissues, a fresh laceration is made by its "removal. 

In desperate cases of hemorrhage internal remedies 
are usually resorted to. 

General Considerations. — Haste in sx-tracting .should 
be avoided; the hand .should never move faster than 
the eye can follow. The tooth should be under com- 
plete observation from the time it is graspe<l bv the 
forceps till it is out of the mouth. The head of the 
patient should be firmly fixed, and under the control 
of the left hand or arm. 

While considerable force is necessarj' to extract a 
tooth, the force should be so guarded and moderated 
as not to endanger surrounding parts. No jerks or 
sudden puUs are allowable. 

The forceps should never grasp the crowns of teeth 
alone, as the crown will usually break off, leaving the 
root undisturbed, but should engage the tooth at its 
neck, or a little higher up if possible. 

In extracting roots the beaks of the forceps should 
follow down between the root and its alveolus till a 
firm hold is obtained. 

The cutting through of gum and alveolus with a root 
forceps is not a desirable procedure, but is allowable in 
certain cases. 

An excellent substitute for a dental chair is a rocking 
chair with medium high back, a pillow thrown over the 
back forming a good head-rest. 

William Hen-rt Potter. 



Telosporida. — The group of Sporozoa in which 
spore-formation is distinct from the trophic phase of 
the life cvcle. See Protozoa. A. S. P. 



Tendons and Their Sheaths, Injuries and 
Diseases of. — It is most unusual to find tendons 
diseased independently. Morbid conditions of the 
tendons are so commonly the result of disease in their 
sheaths that in most systematic treatises they are not 
separately described. Owing to their dense fibrous 
structure and an intrinsic blood supply that is far 
from abundant, they lend themselves more easily 
to disturbances of nutrition than to invasion by infec- 
tious processes. Arcoleo' has shown experimentally 
that tiie intactness of the sheath is necessarj- for the 
perfect nutrition of the contained tendon; but, on 
the other hand, that the complet-e removal of the 
sheath is not followed by necrosis of the tendon. 

DisE.\SES OF Tendons. — Tlie most frequently ob- 
served morbid conditions of tendons themselves have 
been in cases of the so-caUed "snapping finger" 
(schneUender Finger, doigt a ressort). This consists 
of a sudden interference with the movements of ex- 
tension and flexion, or of either alone. It occurs 
always at the same period of the movement, and is 
overcome with a peculiar snap, cither as a result of 
great muscular exertion or with the assistance of the 
other hand. In some instances its nature has re- 
mained obscure, but operations for its relief have dis- 
closed a nodular thickening of the t<>ndon in quite a 
number of instances. It is. under the.se circumstances, 
probably most often of traumatic origin, but has on 



123 



Tendons, Injuries and 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



rare occasions been ascribed to tuberculosis, gout, 
syphilis, and neoplasms. Operative removal has 
been almost invariably successful in its treatment; 
this may usually be accomplished without completely 
severing the tendon. 

With this exception, disease of tendons wUl almost 
invariably be found coincident with or consecu- 
tive to primary di.sease of the sheaths. Malignant 
growths, tuberculosis of articular origin, and acute 
suppurative processes frccjuently involve the tendon 
sheaths in their extension. These do not require 
separate description in this place. 

In consec|uencc of overexertion or traumatism, there 
is somethncs observed in the extensor tendons of the 
hand (less often in the leg) an acute, dry inflamnriation 
of the sheaths, tcnomjnovitis acuta sicca. It is_ apt 
to occur in persons whose occupations necessitate 
excessive use of a particular muscle or group of muscles, 
and especially if there is superadded to the accustomed 
amount a period of forced labor carried beyond the 
jjoint of fatigue. The disease has been observed with 
a certain frequency ifi washerwomen, pianists, fencers, 
carpenters, and gymnasts, being in them localized 
at the wrist. .'Vt "the ankle it occurs frequently in 
porters, and infantrymen, and still more often in 
women operating sewing machines. The prolonged 
use of the hand trephine has occasionally accounted 
for its appearance in the surgeon's wrist. A fibrinous 
exudate upon the surface of the tendon and its sheath 
gives rise to a rubbing or creaking sensation to the 
examining hand, whence the name "tenalgia crepi- 
tans." It has in some instances also been considered 
!is the result of gonorrhea or syphilis. Under these 
conditions, but also in their absence, a serous effusion 
may appear. When it does so, the crepitation is 
masked by it to an extent proportionate to the amount 
of fluid which has been poured into the sheath. Con- 
siderable pain and disability may be associated with 
it. It may be made to subside promptly by fixation 
of the part by splints, or, still better, by a plaster-of- 
Paris dressing, this to be followed in from ten to 
fourteen days by a course of massage and superheated 
air. 

Acute suppuration of the tendon sheaths occurs most 
frequently in consequence of infected wounds, but 
may result by extension from phlegmonous processes 
without demonstrable traumatic origin. It is of 
especial frequency in connection with wounds of the 
fingers, when it is spoken of as thecal whitlow. We 
have here to deal with a most painful septic condition; 
redness, swelling, intense pain, and throbbing are 
present. The constitutional symptoms are, or may 
rapidly become, alarming, and unless incision of ample 
length is promptly made the tendon will be completely 
lost by slough; this being escaped, adhesion between 
the tendon and its sheath occurs, so that its function 
may be completely abrogated. Prompt and free 
incision with thorough drainage and preferably moist 
antiseptic dressing (1 to 5,000 sublimate), to" be fol- 
lowed by elevation of the affected part, may be de- 
jiended upon to avert these unfortunate termina- 
tions in the greater number of cases. For this reason 
such temporizing measures as poulticing, the applica- 
tion of cold, and incisions of very limited extent are to 
be avoided. 

Chronic simple inflammation of the tendon sheaths 
may be considered as occurring very infrequently. 
To such an extent is this true that all chronic disease 
of tendon sheaths is ascribed by some writers to 
tuberculosis. It has been shown, however, that this 
is not justifiable, but that chronic simple tenost/novitis 
may occur as a dry, serous, or hemorrhagic inflam- 
mation. The dry form is characterized, like its 
congener of the acute variety, by crepitation upon 
movement of the tendon in its sheath. Gout and con- 
tinuous overexertion have been held responsible for 
it. The serous variety has doubtless been looked 
upon as tuberculous by many, but is sometimes the 

124 



result of trauma, rheumatism, or gonorrhea. Blake^ 
has reported a case in which operation and subsequent 
careful microscopic e.xamination showed its non- 
tuberculous character beyond question. According 
to Lejars, it is most frequently due to repeated trau- 
matisms, and must sometimes be regarded as a disease 
of occupation. It presents itself as a fluctuating 
swelling in the course of the affected tendon, the 
movement of which is usually interfered with or is 
productive of discomfort. It is frequently difficult 
to distinguish it from tuberculous hygroma (see below) 
without exploratory incision. Aseptic incision is, 
however, the treatment most likely to be successful. 
The hemorrhagic variety has, in the few reported cases, 
been the sequel of trauma. Juvara' has reported 
three cases of such effusion into the sheaths of the 
radial extensors. There was present an almond- 
shaped, fluctuating tumor which could be made to 
slip about by pressure. There was no crepitus to be 
obtained. 

Tuberculosis of the tendon sheaths is by all means the 
most frequent of the chronic conditions affecting these 
structures. It is, however, less often primary than 
secondary. In this latter case it usually occurs by ex- 
tension from a bone- or joint-focus. This is frequently 
observed at the wrist and ankle. As a primary con- 
dition it is, however, far from rare, and is frequently 
found in individuals showing no other predisposition 
to tuberculous infection. For this reason, and be- 
cause its course may be extremely chronic and un- 
accompanied b}' great disability, its real nature is 
often not appreciated, and is considered rheumatic. 

Three forms are usually described, but should not be 
considered as pathologically distinct, as they are fre- 
quently found in combination. The first form may be 
described as the tuberculous hygrofna. This presents 
itself clinically as an effusion of serous character, found 
most often at the wrist and hand, where, being con- 
stricted by the annular ligament, it is also known as 
compound ganglion. In its symptoms it does not differ 
materially from simple serous chronic tenosynovitis. 
Its progress usually is ciuite slow, and it may be objec- 
tionable to the patient solely on account of the defor- 
mity which it causes. Upon incision there is found in 
addition to the serous exudate a formation of miliary 
tubercles upon the lining of the sheath. If in addition 
we find the so-called "rice bodies," we are dealing with 
the second form. These may vary greatly in size 
and number. Usually this is in inverse proportion. 
These bodies derive their name from their resem- 
blance in size and color to grains of boiled rice. They 
are frequently smaller, however, and, on the other 
hand, the writer has removed from the palmar sheaths 
a number of the size of large cherries. For this reason 
they were easily palpated before incision was made. 
This is, however, not usually possible, for the reason 
that abundant serous distention is often present, and 
because such large size is exceptional. There is 
commonly imparted to the examining hand a charac- 
teristic sensation akin to crepitation, but to be dis- 
tinguished from it. The fluid may be sufficient to 
maice these bodies impossible of recognition without 
incision. 

The formation oi fungous granulation tissue upon the 
serous lining of the sheath and even upon the tendon 
itself is the distinguishing mark of the third variety. 
This tuberculous tissue is identical with that found in 
"joint fungus," and gives rise to doughy, elastic swell- 
ings of the sheaths. It is distinctly less benign than 
the preceding forms, inasmuch as the tubercles are 
actively disintegrating. The peritendinous struc- 
tures are, therefore, soon involved; caseation, lique- 
faction, and the formation of fistula? are apt to be 
observed in rather rapid development. Secondary 
involvement of neighboring joints may occur. This 
variety, in contrast with the other two forms, causes 
marked disability from the first, and is frequently very 
painful. If the disease is allowed to progress, the 



REFERENCE HANDBOOK OF THE MEDIC.\L SCIENCES 



Tendons, Injuries and 
l>Kea»e!» or 



contiguous structures may suffer to a great extent; 
the swelling becomes verj' great, and amputation 
may become necessary as a last resort. On the 
other hand, if employed before such extensive spread 
has occurred, radical operative measures are almost 
invariablv successful if sufficiently thorough. Treat- 
ment by iodoform injections has "not proved satisfac- 
tory in this country, although much lauded by some 
European authors. In the hygromatous form, evacua- 
tion of the rice bodies and fluid with scraping of 
the sheath is, as a rule, all that is required. In the 
fungous form it is best to remove all infected tissue, 
and, therefore, to practise the complete extirjjation 
of the tendon sheath. This is usually followed by 
complete restoration of function if aseptic healing is 
obtained. 

Beck* has described a chronic inflammation of the 
tendons and tendon sheaths of the hand characterized 
by the formation of granulation tissue and chalky de- 
posits; he has named this tendovaginitis prol'ifera 
calcarea. 

bcjTRiES OF Tendons. — Dislocation of tendons occurs 
as a rather uncommon accident, and in most of the re- 
ported cases the peronei tendons were concerned. 
After a traumatism to the foot, usually of the kind 
spoken of as sprain, great disability of the foot is ob- 
served, and the tendon of the peroneus longus, with 
or without that of the brevis also, is found to have 
slipped from the groove behind the external malleolus, 
and may be felt as a prominence in front of it. The 
replacement by manual pressure and retention by 
means of a crescentic pad and adhesive strips are 
easily accomplished. In most of the reported cases, 
however, recurrence of the luxation has occurred, and 
on this account operations of narrowing the sheaths 
or deepening the bonv groove have been successfully 
done. Shaffer (Fitzhugh^) holds the accident to be 
due to a shortened condition of the gastrocnemius 
and peroneal tendons. In three cases cure was ob- 
tained by stretching these by means of his traction 
shoe. 

Dislocation of the long head of the biceps has been 
described in a few cases, but on anatomical and experi- 
mental grounds there is cause for doubting the pos- 
sibility of this. 

Subctitaneous rupture of tendons occurs rather fre- 
quently and may be due to unusually violent muscu- 
lar action. In some cases it would appear that a 
pathological condition of the tendon or the neighbor- 
ing structures was to blame. The rupture usuallj- 
occurs near the union with the muscle beUy or at the 
bony attachment of the tendon. It is ordinarily 
felt as a sudden snap with disability, due to loss of 
function of the affected muscle. Often the gap in the 
course of the tendon can be felt, and the muscle itself 
is more prominent than usual on account of its con- 
traction. Although fixation of the limb in such a 
position as will tend to approximate the torn ends 
often secures satisfactorj- healing, it is not wise to 
depend upon this in the case of important muscles, 
but rather to approximate and suture the ends through 
an incision. The tendons most frequently torn are 
those of the biceps brachii, the plantaris (tennis leg), 
quadriceps extensor, ligamentum patella;, and tendo 
Achillis. 

Open wounds of tendons occur verj' frequently, and 
especially about the wrist and hand. They may be 
incised or lacerated. When incompletely divided, 
union wiU occur without injury to function. ^^ hen 
completely divided, retractioa of the muscular end 
takes place; the ends become adherent to the sheath, 
and union between them does not occur. Exception 
to this must be taken in the case of certain operative 
wounds, such as tenotomy of the tendo Achillis and 
other tendons of the foot. 

Division of the tendons calls for the approximation 
and union of the ends, and is especially important in 



the hand, where the usefulness of tlie member may 
depend upon it. The muscular end is oft<?n difficult 
to find, and may necessitate considerable enlargement 
of the wound to make such 'union possible. Cen- 
trifugal wrapping of the extremity with an elastic 
rubber bandage will oecasionally bring the proximal 
end to view, thus avoiding the necessity of extensive 
incision. Suture should be done with silk or catgut 
(chromicized). The sheath may often be sewed over 
the tendon. As the sutures tend to tear out, one of 
the methods illustrated here may be emploved to 
prevent this (Figs. 47.52 and 47.5.3). In suturing ten- 
dons Lange's advice, never to pass the needle through 




FiQ. 4752— Suture of Divided Tcadons. 

the entire thickness of the tendon, will be found 

most useful. 

When secondary suture must be done, i.e. after the 
external wound has healed, it may be extremely 
difficult or even not feasible to find the proximal end. 
In this case tendon transplantation h;is been done 
{nde infra). The proximal end having been found, 
it may be impossible to approximate it to the distal 
sufficiently to make ordinary suture practicable. In 
this event tendon lengthening may be done by split- 
ting the dLstal end, as shown in Fig. 4755, or a" bridge 
of silk or silkworm gut may be made, viniting the ends 
and serving as a framework upon which new tissue is 




afterward formed. Silk will usually be found pref- 
erable for this purpose. 

Surgery op the Tentx>ns.— In addition to those 
above described, operations on tendons are done for a 
variety of conditions. The most frequent of these by 
far is tenotomy, simple division of a tendon. This 
may be open or subcutaneous. The open operation 
consists in making an incision parallel with the tendon; 
the tendon is then divided upon a grooved director 
in the open wound. The method is one of choice 
when it is necessarj- to avoid important structures 
(e.g. the peroneal nerve in division of the biceps 
femoris), or where the anatomical situation makes 



Fig. 4754. — Jones' Tenotome. 

complete division of tendons or muscles not feasible 
by the subcutaneous method. The muscular variety 
of wryneck may serve as an example of this; likewise 
the adductors of the thigh in cases of spastic infantile 
paralysis. Otherwise, on account of it,s simplicity 
and the ease and certainty of the healing process, the 
subcutaneous method will be chosen. It may be done 
from within outward or from without inward. The 
former is the method of choice. The tenotome is a 
knife with a short blade (1.5 to 2.5 centimeters) at the 
extremity of a long shank (2 to 2.5 centimeters), and 
may be pointed or blunt. The length of the blade 
should equal the width of the tendon to be cut. The 
tenotome of Robert Jones (Fig. 4754) is of especial 

125 



Tendons, Injuries and 
Diseases of 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



utility because the cutting edge is straight and be- 
cause" its proximal end terminates abruptly in a right- 
angled shoulder. It is easy, for this reason, to Imut 
the cutting to the tendon itself. An assistant hold- 
ing the part so as to put the tendon on the stretch, 
the operator feels for the edge of the tendon and 




-Length 



inserts the tenotome behind this with the flat of the 
blade parallel to the tendon. The tenotome is then 
pushed through until its point is felt on the opposite 
side. The edge is then turned toward the tendon, 
and' the division is made by a rocking motion. The 
tendon is felt to vield suddenly and often with an au- 




FiG. 4756. — Lengthening of Tendon. (Plastic tenotomy.) 
A, Incision to be employed in di%iding the tendon; B, mode of 
auturing the divided ends. 

dible snap. The knife is then withdrawn and the 
minute opening is closed by pressure with a compress 
of gauze. The oper.ation should be done with all 
a-septic precautions. The wound in the tendon heals 
by the organization of the blood clot between the 
divided ends; these soften and become fused with the 
new fibrous tissue. For some 
time this has the appearance, 
both gross and microscopic, 
of scar tissue. After about 
three months the new tissue 
can scarcely be distinguished 
from the old. Immediately 
after the division of the ton- 





FiG. 47.^7. — Subcutaneous Plastic Tenotomy of the Tendo ,\chilhs 
after Bayer. The tenotome is introduced in the midhne of the 
tendon at the calcaneus and at the muscle, and at each location 
one-half of the tendon is di\'idedin the direction of the arrow, o, 
The line bet ween the two points of i nsertion of the tenotome along 
which the fibers become loosened and sUde past each other;6shows 
the manner of division of the lateral half of the tendon. (From 
Vulpius and Stoffcl.) 

don the necessary correction in the position of the 
part is made, and fixation is usually accomplished by 
plaster of Paris applied over the aseptic dressing. The 
operation is most frequently done upon the tendo 
Achillis for clubfoot, either congenital or paralytic; 
the tibialis posticus and anticus, and the plantar fas- 
cia are often divided for the same purpose. Tenot- 

126 



omy may be indicated for the lengthening of any con- 
tracted muscle, or when it is desirable for any reason 
to exclude the action of a muscle, e.g. the tendo 
Achiilis, in the correction of anterior bow-leg. 

In some instances, and especially in spastic paraly- 
sis, the overcorrection of deformity causes such ex- 
tensive separation of the divided ends of a tendon that 
their subsequent union may be in doubt. For the 
avoidance of this plastic tenotomy or tendon lengthen- 
ing is often done. An incision is made over the 
tendon, which is then split longitudinally for a dis- 
tance equal to the amount of lengthening desired. 
Incisions are then made at right angles to this at either 
extremity of the longitudinal cut and in opposite direc- 
tions (Fig. 4756, A). Fig. 4756, B shows the method 
of uniting these flaps. For the tendo Achillis, Bayer 
has proposed a subcutaneous method in place of his 
original plastic tenotomy (Fig. 4757). This consists 
in cutting through half the width of the tendon above 
and below subcutaneously. Upon making forcible 
dorsal flexion of the foot the tendon will now split 
lengthwise and the effect be the same as in Fig. 
4756. It has the additional advantage of avoiding 
adhesion between tendon and sheath. The writer 
has done the operation repeatedly with satisfaction. 

Of especial interest in connection with the surgery 
of the tendons are the uses to which they have been 
put for the amelioration and connection of the disa- 
bilities and deformities of paralytic origin .and in 
such instances in which the equilibrium between the 
muscles controlling a joint has been permanently lost 
either by trauma or disease. The largest group of 
cases in which the tendons have been utilized for such 
reparative purposes results, of course, from acute 
anterior poliomyelitis. Always quite numerous in 
all civilized communities these disabilities have 
assumed a position of striking importance during the 
past ten years because each summer during this period 
has been characterized by the appearance of anterior 
poliomyelitis in epidemic form in the northern part 
of the United States. During the summer of 1916 
these epidemics assumed unexampled proportions. 
It is estimated that not less than 12,000 cases were 
reported in the United States during this period, of 
which number perhaps 9,000 survived. Of these, 
much the greater part have doubtless been left with 
residual and permanent paralj'sis, particularly in the 
lower extremities. It is well known that in acute 
anterior poliomyelitis the paralysis, C}uite extensive 
to begin with, is recovered from during the first few 
months, so that after a year has passed there remains 
an involvement, of more or less circumscribed extent 
and of permanent character. In some of the most 
unfortunate cases there persists a flaccid paralysis 
of all the muscles of a part; in others the paralyzed 
muscles so greatly overbalance in number and 
strength the unaffected ones that the latter are of 
inconsiderable functional use or, on the contrary, 
act simply to produce a deformity by their unopposed 
action. On the other hand, many instances are to 
be found in which disability and deformity are pro- 
duced by the loss of function in one or two of the 
more important muscles. Thus an isolated paralysis 
of the tibialis anticus results in marked valgus de- 
formity at the ankle; paralj-sis of the peroneus brevis 
and longus in still more pronounced varus deformity. 
Practically complete paralysis of all of the long foot 
muscles produces the so-called "dangle foot," while 
the persistence of power in the gastrocnemius-soleus 
group alone usually means the development of equino- 
varus or club-foot. With the prevention of such de- 
formities we shall in this place not concern ourselves, 
nor indeed with the correction of the deformity itself 
once it has occurred, except to say that such correc- 
tion should constitute a separate step, antecedent and 
distinct from the procedures involving the tendons and 
which are presently to be described. As a further 
introduction to a discussion of the surgical procedures, 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



Tendons, Injuries and 
Dlseaset) of 



involving the tendons and intended to prevent or 
ameliorate the disabihties produced by poliomyehtis 
it Is to be stated dogmatically that they should not 
l>c considered until there can no longer be a question 
(if possible further recovery of muscle power. It 
might be safely said that not less than two years should 
elapse from the onset of paralysis before any operative 
])r(icedure should be undertaken other than such 
as calculated to merely correct any fLxed deformity 
which may be present. 

This minimum period of recovery having termin- 
ated, in the presence of a paralytic disability, now 
]iresumed to be of permanent nature, we may con- 
sider the feasibility of certain tendon operations for 
its relief. Such operations may be considered under 
three heads: (1) Operations having as their object 
the restoration of the muscular equilibrium of the 
joint and aiming at practical restitution of the usual 
function of the part: tendon transplantation. (2) 
Procedures in which the tendons of paralyzed muscles 
are utilized as stays or ligaments with the idea of 
preventing the development of deformity which must 
otherwise be inevitable unless obviated by the per- 
manent use of apparatus: tendon implantation, 
tenodesis, tendon fixation. (3) By combining both 
of the foregoing methods, we may conceivably 
achieve a result functionally more satisfactory on the 
one hand and on the other much more likely to endure. 

Tendon Transplanlnlion. — The intent of this pro- 
cedure is to restore the balance of muscular control 
of a joint or part of an extremity, which has been 
overthrown by loss of function on the part of one or 
more muscles, whatever the cause may be. As before 
said, the commonest cause is the residual paralysis 
of acute anterior poliomyelitis. As the result of 
an abundant experience, tendon transplantation has 
now been given its proper evaluation. The effect 
has been to narrow greatly its field of usefulness as 
compared with the indications of ten years ago, as 
well as to standardize its technical details to a con- 
siderable degree. It must be acknowledged to-day that 
the complicated operations which were formerly in 
vogue, and which frecjuently involved several muscles 
controlling a joint, have been disappointing in their 
functional results. It is furthermore now apparent 
that the muscle transplant, in order to be functionally 
efficient in its new situation, must be akin to the 
paralyzed muscle, which it is proposed to supplant, 
in its own primary function. It is now realized that 
we cannot at will convert a flexor into an extensor, 
an adductor into an abductor and obtain truly 
efficient muscular action. It has become apparent 
that we were frequently deceived as to the effect of 
such operations by reason of the fact that the 
transplanted muscles, under these circumstances, 
acted for a time simply as mechanical stays, prevent- 
ing the recurrence of deformity by serving as liga- 
ments. Not being structurally adapted to such 
purpose, however, they stretched before long, and 
permitted the recurrence of deformity and imbalance. 
In addition, we have had to reconstruct our notions 
of the mechanical conditions under which transplanta- 
tions may be done which might be otherwise appro- 
jjriate from the functional standpoint. The power of 
the transplant must stand in some adequate pro- 
portion to that of the paralyzed muscle, or supplant. 
Thus, we can realize the difficulty of this problem by 
remembering that the power of the gastrocnemius- 
soleus is practically equal to that of all the anterior 
muscles of the foot combined. The tendon of the 
transplant must not liecome adherent to the surround- 
ing structures, else the contraction of its muscle fibers 
will be of no functional avail; this will usually require 
that the transplant be drawn from its sheath and be 
passed through the sheath of the supplant itself. 

Since in this place we are concerning ourselves 
chiefly with the surgery of the tendons and not that 
of the muscles and certainly not with the larger ques- 



tion of paralytic di.sabilities, the general discussion of 
operative plans cannot now be undertaken. We 
shall have to confine ourselves to such matters as 
concern the tendons themselves. In this country, 
the original plan of Nicoladoni, which was supported 
later by Vulpius, of sewing the tendon of the trans- 
plant to the tendon of the paralyzed supplant has 
steadily lost favor because of dissatisfaction with the 
end results. This is, however, to a considerable 
degree true also of the method of Lange in so far as it 
involves the use of considerable lengths of silk braid 
for the prolongation of the transplant to an insertion 
into the periosteum and ligament. It has become 
apparent, however, that the attachment of the trans- 
plant to its new point of in.'sertion must be of such 
firm character as to withstand a great tendency to 
stretch under continued stress of function. For this 
reason the method of attaching to bone and perio-steum 
is much to be preferred. Strictly aseptic braided 
silk of sufficient thickness is to be recommended not 
only because of its own permanence, but also because 
of its tendency to stimulate the formation of new con- 
nective tissue which must, after all be rle])ended upon 
as a definite safeguard. In applying the suture to the 
tendon itself, Lange's admonition should be remem- 
bered, namely, that the needle should at no time pass 
through the entire thickness of the tendon. 

Tendon Implantation [Tenodesis). — Unsatisfactory 
results after tendon transplantations of the more 
complicated kinds and the difficulty of obtaining 
satisfactory transplants for certain muscles of great 
functional importance, such as the peronei in ca-ses 
of paralytic eciuinovarus, have led operators to the 
idea of converting the tendons of the par.ilyzed 
muscles into ligaments which are permanently to 
prevent the development or recurrence of the paralytic 
deformity. In so doing there is abandoned the hope 
of reproducing in any way the active functions of the 
paralyzed muscles. The operation, which originated 
with Codivilla, has recently been revived by Gallic of 
Toronto. There follows a brief description of the 
operation as practised in the case of varus deformity 
at the ankle from paralysis of the peroneus longus and 
brevis. Through an appropriate incision the peronei 
tendons are removed from their sheaths; thus must 
be done with particular freedom in the case of the 
peroneus longus so that it may be made to take a 
straight course from its place on the external border 
of the foot to the front of the external malleolus 
where it is to be implanted. On the front of the lower 
end of the fibula a vertical incision, one or two inches 
in length, is made through the periosteum and the 
edges of the cut periosteum are jjushed aside by means 
of an elevator, exposing the bone. With a narrow 
gouge chisel a deep furrow is cut in the fibula, the 
length of the periosteal incision. The same thing 
is done on the posterior aspect of the lower end of the 
fibula. The foot is now brought into an overcor- 
rected position, i.e. valgus or decided pronation, and 
thus held by an assistant until the conclusion of the 
operation. The tendon of the peroneus longus is 
now seized with a clamp and placed in the anterior 
farrow under sufficient tension to hold the foot in the 
new position. Silk sutures are passed through the 
periosteal flaps and the tendon so as to hold it in place. 
In like manner, the peroneus brevis is sewed into the 
posterior furrow. The skin wound is sutured, an 
a.septic dressing applied and, over this, a plaster dress- 
ing holding the foot In distinct pronation. This 
plaster is worn for eight weeks and is best followed by 
another or by a protective brace for a still longer 
period. 

The immediate results of this operation when 
properly performed In suitable cases are unques- 
tionably pleasing. In the presence of normal antagon- 
ists, however, it seems inevitable that the implanted 
tendons must stretch sooner or later and permit more 
or less recurrence of the deformity and this has been 

127 



Tendons, Injuries and 
Diseases of 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



the author's experience in several cases. Here, as in 
the case of tendon transplantation, several years of 
observation are required as a real test of usefulness. 
The Combined Operation o} Staff el. — In this operation 
there are combined the essential features of tendon 




Urevis is ready to be laid in t 
(Gallic, Annals of Surgery.) 



1 1 ! ■• 1 ' ' >hr 11^ I.ongus has been fixed in th( 
Ml .M;ill.>,li,-, Hi.atiie Tendon of the Peroneu 
; Trough Prepared forit behind the Malleolus 



transplantation and tenodesis. The object of this 
combination is to relieve the transplant of the duty of 
acting as a retentive agent in preventing the recur- 
rence of deformity in order that it may be able to 
fulfil its function as a contractile organ. Stoffel 
has called attention to the necessity for paying 
greater attention to the mechanical conditions under 
which transplantations are done and to the fact 
that gross violation of the mechanical principles upon 
which muscular action is dependent must be followed 
by disappointment in the functional result. Accord- 
ing to Stoffel the prerequisites for successful trans- 
plantations may be discussed under three heads: 

1. The Transplant Must Bear a Fairly Close Mor- 
phological and Functional Relationship to the Muscle 
Whose Function it is to Supplant. — Thus, to use 
StofTel's own illustration, the extensor longus hallucis 
may well be used to supplant the paralyzed anterior 
tibial because of its similar course and position. The 
contrary would be true of the flexor longus hallucis 
if used for the same purpose. It would require to be 
brought through the interosseous membrane to the 
front of the leg and its fibers would, therefore, be 
given an angulated course; furthermore, a consider- 
able number of its fibers would have to be dissected 
from their insertion, and their action would, therefore, 
be lost. 

2. In Order to Possess Effective Contractility the 
Transplant Must be Fastened to its New Point of In- 
sertion Under Physiological Tension Only. — Quite the 
contrary has been the practice; we have been sewing 
the transplant to its new insertion under considerable 
tension. This has the effect of diminishing the ampli- 
tude of contraction to such an extent as to interfere 
very greatly with the functional efficiency of the 
transplant. 

3. The Transplanted Muscle Must not be Used 
to Hold the Limb in a Corrected Position. — This for 

128 



the reason that the transplant would then be under 
much more than physiological tension, which is forbid- 
den by postulate No. 2. We shall do much better by 
making of the paralyzed muscle itself (the supplant) 
a temporary ligament; it may be sewed to periosteum 
and deep fascia under tension enough to main- 
tain the desired position of the limb. It is 
t rue that it will stretch before long. Experi- 
ence has shown, however, that it may be de- 
pended upon as a stay until the strength of 
the transplant has been cultivated to such a 
degree as to make it no longer necessary. 

During the past two years I have obeyed 
the three postulates of Stoffel in m}^ trans- 
plantations as far as possible. The result has 
been extremely gratifying to me in that I have 
obtained efficient function in the transplanted 
muscle to a degree hitherto unattainable. For 
the sake of illustration I shall describe a simple 
case, such as I have repeatedly operated and 
as given by Stoffel*" in his paper. The case 
is one of equinovalgus of the foot produced 
by paralysis of the anterior tibial muscle. The 
long extensor of the great toe is intact and is 
to be used as the transplant. The equinus 
deformity is first overcome by means of sub- 
cutaneous plastic tenotomy of the tendo 
achillis. An incision is now made over the 
tibialis anticus just above the annular liga- 
ment. The tibialis anticus tendon is pulled 
out of the wound with sufficient tension to 
bring the foot into a slightly over-corrected 
position, i.e. into supination and dorsal flexion. 
While held in this position by means of the 
tibialis anticus its tendon is now sewed fast 
to the periosteum of the tibia and to the deep 
fascia of the leg with strong silk sutures. An 
incision is made on the dorsum of the foot 
between the tendon of the extensor longus 
hallucis and the insertion of the tibialis anticus. The 
tendon of the extensor longus is cut at this level. This 
tendon is now drawn out of the upper incision from its 




Fig. 4759. — Tendon Transplantation alter Stoflel's Method. 
1,1, Extensor longus digitorum muscle ; 2, extensor hallucis longus 
(healthy); 3, 3, tibialis anticus (paralyzed); 4, tibia; 5, fascia 
cruris; 6, 6, surface marking of the tendon of the tibialis anticus. 

compartment in the annular ligament and is passed 
under the annular ligament in the same compartment 
with the anterior tibial and is made to emerge again 



REFERENCE HANDBOOK OF THE MED1C.\L SCIENCES 



TeratoloKT 



from tlie wound on the dorsum. It is then sewed 
firmly to the periosteum with strong silk, in com- 
pany with the insertion of the anterior tibial. The ex- 
tensor longus hallucis now has a direction and inser- 
tion practically identical with that of the anterior tibial 
and is placed here under physiological tension. Under 
these conditions it is not too much to expect the trans- 
planted toe extensor to satisfactorily act as a tibialis 
anticus, and if the operation has been properly planned 
and the after-treatment has been appropriate, the foot 
may well become entirely normal in function and ap- 
pearance save for the loss of action of the toe extensor. 
This in shoe-wearing persons is entirely insignifi- 
cant and may, in fact, be obviated by uniting the 
distal end of the extensor hallucis tendon with the 
extensor of the second toe. 

It will be readily seen that the adoption of these 
principles will rule out the quite complicated schemes 
for operation, such as have been recommended chiefly 
by Vulpius, and at the same time will exclude at- 
tempts to convert a flexor into an extensor and rice 
I'crsa. There is, in my judgment, good reason to 
believe that specialized action of the kind desired 
is rarely or never attained after such operations, 
anyhow. 

The natural conclusion which must be drawn as 
the result of these considerations, is that complicated 
operative plans do not result in sufficiently specialized 
action to justify them. Anatomical research explains 
this and abundant clinical experience confirms it. 
When, therefore, a simple and direct operative plan 
cannot be entertained because of the extent and char- 
acter of the paralysis, tendon transplantation should 
not be the operation of choice. We must either resort 
to fixative operations, such as arthrodesis or tendon 
fixation, or abandon the idea of operation altogether, 
save as it may be required for the correction of fixed 
deformity. 

While Stoflfel's plan of operation lends itself readily 
to most of the cases of valgus deformity in the foot, 
this is not true with many of the cases of varus or 
equinovarus of paralytic origin. It is peculiar to 
the incidence of the valgus cases that while the an- 
terior tibial is paralyzed, the extensor longus hallucis 
is most often intact and therefore available as a 
transplant. In the varus cases, on the other hand, 
■we most often have to deal with the loss of both 
peronei with or without the paralysis of the common 
exten.sor. .\s has recently been pointed out by Motti.' 
we shall, under these conditions, have to be satisfied 
with a less well-specialized set of movements and con- 
tent ourselves with restoring the equilibrium to a 
large extent. Lange seeks to accomplish this by 
connecting the tibialis anticus with the lateral side of 
the foot by means of a silk tendon. I have not been 
satisfied with my trial of this method, but prefer the 
plan of Codivilla, which transfers the whole of the 
tibialis anticus to the external border of the footand 
replaces it by means of the extensor longus hallucis. 

While tendon transplantation is by all means to be 
considered a very great advance in the treatment of 
partial paralysis and of paralytic deformities, unrea- 
sonable things should not be expected of it. The most 
satisfactory results by far are obtained when only one 
or two muscles are paralyzed, and here the cure may 
under favorable conditions be practically perfect. 
When a number of important muscles must be substi- 
tuted for, much less is usually accomplished. A better 
position of the limb, making the wearing of apparatus 
easier, because of simpler needs for it, is all that is fre- 
quently accomplished, and it is likely that in some 
cases arthrodesis would be of more beneficent effect. 
The success of transplantation depends, however, 
not only upon the selection of the proper muscles for 
grafting and a correct operative technique, but in no 
less desree upon attention to even the minor details 
of the after-treatment. The full benefit of the opera- 
tion is usually not to be observed until some months 

Vol. VIII.— 9 



afterward, and the total improvement is sometimes 
not gained until a period of as much a.s two years ha.s 
expired. Sometimes benefit from the operation is 
found to be transitory; a few months afterward the 
patient is found to be in the old condition. In this 
case careful investigation will sometimes disclose the 
cause of failure in improper selection of energizing 
muscles, and one may with hope of success resort to 
secondary operations. .\lbert H. Freiberg. 

Referen'ces. 

1. .\rcoleo: Gazzctta degli Ospedali, 189S. No. 15. 

2. Blake: Annals of Surgery, xxxiv., p. 577. 

3. Juvara: Kevue de Chirurgie, June 10. 1902. 

4. Beck: New York Medical Journal, 1901, p. 70S. 

5. Fitzhugh: Trans. Am. Orthopedic .^ss'n. 1902. 

0. Stoffel: Zeitschrift fOr orth. Chirurgie, xziiii., p. 602. 

7. .Mutti: Deutsche Zeitachrift fQr Chirurgie, Bd. cxxxiii., p. 99. 



Tenon, Jacques Ren^. — ^Distinguished French 
anatomist, surgeon, and oculist. Born in 1724. 
He began the study of medicine at Paris in 1741, and 
three years later he received the appointment of 
.\rmy Surgeon of the First Class. He took part in 
the campaign in Flanders, and upon his return to 
Paris he won, by competitive examination, the posi- 
tion of chief surgeon of the Salpctri^re Hospital. 
A little later he was made a member of the Royal 
Academy of Surgery, and later still he was appointed 
to the Chair of Patliologv in the Faculty of Medicine. 
He died Jan. 19, 1816. 

Tenon is known to medical men of the present time 
by reason of his having discovered and carefully de- 
scribed the fascia of the eyeball now called Tenon's 
capsule. Of his many published writings the fol- 
lowing deserve to receive special mention: "Recher- 
ches sur les cataract es capsulaires, etc.," in the 
Memoires de I'Acad. des Sciences. March, 19, 17.55; 
"M(5moires sur I'anatomie, la pathologic, ct la chi- 
rurgie," Paris, 1806; and " M6moirc sur les hdpitaux 
de Paris," Paris, 1788. A. H. B. 



Teratology. — Derived from the Greek ripat, a 
monster, and Xo7os, a discour.se this science in the 
broadest sense of the word deals with abnormal de- 
velopment in the fields of both zoologj- and botany; 
in its more restricted and usual sense it deals with 
abnormal animal embrj-ology, and thus stands in 
the same relation to embryology that pathologj' does 
to normal histology. 

Primarj' malformations are those which arise from 
the action of forces which give rise either to arrest of 
the normal impulses, to growth, or to a perversion 
of the normal impulses to growth. Primarj- monsters 
are the result of inherent faulty impulse and stimulus. 
Secondary malformations are those which arise from 
the action upon the embrj-o of forces external to the 
growing embryo. Fetal disease is excluded from the 
subject of teratology, properly considered, for the 
reason that disease of the embryo is not properly a, 
part of the developmental condition. Maternal 
disease upon the other hand, may be properly con- 
sidered under the head of causes which make for or 
contribute to secondarj- malformation. 

The term monslcr is reserved for those abnormalities 
which exhibit marked and fundamental defects, many 
of them of a hideous nature. Many such creatures 
are incapable of continued life after the severing of 
the placental circulation. 

The early period of development is the most im- 
portant period of embryonic life, from the standpoint 
of the study of hralolo'gy, for the degree of variation 
from the normal varies, within certain limits, with 
the stage of embryonic life at which the aberrant 
growth commenced. Further the date of the initia- 
tion of the aberrant process, if that date could be 
known, would within certain limits ser\-c to establish 

129 



TerstoloK)' 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



the t^-pe of (leforiuity, for, us the growing and develop- 
ing embryo passes through the various stages of its 
development reminiscent of the phylogenetic history 
of the individual, and as these changes are progressive 
and part of an evolution and not an involution, the 
subsequent development ])roceeds consecutively from 
the stage of embryonic differentiation at wiiich the 
deviation commenced. The fundamental difference 
between minor developmental abnormality and 
extreme deformity is therefore one of degree only. 

HisTORT. — The growth of the knowledge of tera- 
tology parallels closely, of necessity, the development 
of biology and esijecially embryology. Up to the 
year 17.59 when IVn/jJ ])ublished his "Theoria Genera- 
tionis" the subject was shrouded in the blackest 
mj-stery, and such explanations of the causes of 
monsters as existed were largely the result of supersti- 
tion and mystical credulity. This in spite of the 
fact that many of the master minds of the ancient 
world, among them most notably Aristotle, had at- 
tempted to elaborate an adequate theory and ex- 
planation of the occurrence of these phenomena. 
The recognition of the mammalian ovum in 1672 
by de Graaf, and of the spermatozoon in 167.5, led 
to investigation of the growing germ mass and gave 
rise to much scholastic and unproductive speculation. 
It was not until the closing years of the eighteenth 
century and the opening years of the nineteenth 
century that it was recognized that the development 
of the abnormal fetus was the result of certain ordered 
processes, and not the result of mere chance and 
hazard. Since 1S37, when St. Hillaire published his 
"Trait<5de T(?ratologie," progress has been rapid and 
great in extent, until, at this present writing, the 
literature both descriptive and theoretical, is volumi- 
nous. The present trend of the science is in the direc- 
tion of experimental research, and it is to this investi- 
gation into the causes of aberrant development that 
W'C must look for future progress. 

pAtrsATioN. — The question of the causation of the 
primary forms is still open, and its solution is to be 
looked foras part of the explanation of the causes 
and stimuli to normal growth and development. The 
causes of the secondary forms of maldevelopment 
are, as above implied, external, as regards the emljrvo. 
They act by causing injury to the growing fetiis. 
They are mechanical or chemical; among the former 
are hemorrhages, multiple fetuses, with killing or 
distortion of one or more of the fetuses, amniotic 
bands of adhesions causing strangulation of parts 
and determining the level of intrauterine amputa- 
tions of extremities. Chemical agents, excessive 
temperature, and violence act by injuring the embryo 
by way of the placent.al circu'lation. These forces 
may result in immediate death of the fetus with 
immediate expulsion, or the products of conception 
may be retained up to or beyond term. Pressure or 
traction with or without constriction are potent factors 
in the production of deformity and the effects of such 
agents are measured rather bv the duration of time 
durmg which the force is applied than by the intensity 
of the force at any given time. The multiform results 
produced by amniotic adhesions to the fetal surface 
clearly fall within the effects of this class of forces. 
Such deformities are seen fretiuently in the extremities 
and in and about the head, which, because of its 
irregular conformation, offers much surface for the 
attachment of these membranes when abnormal, 
also because of the very wide range of change through 
which the head has to pass in the course of its de- 
velopment. The change once initiated is progressive 
in character. 

Maternal impression as a cause of fetal deformity 
can be dismissed as a relic of the days when the causa- 
tion of fetal deformities was explained upon more 
fantastic grounds than at present. The theory still 

130 



finds place in popular superstition and its chief 
support in reasoning post hoc ergo propter hoc. 

That heredity has an important place in the causa- 
tion of certain primary forms of malformation is clear 
from any extensive study of the subject. Yet up 
to the present time there has been no successful appli- 
cation of the rules of Mendelian heredity to any 
sufficiently extensive series of cases. 

It is not at aU times possible to tell whether a given 
subject is the result of a perverted development or 
the result of a pathological change in an otherwise 
normal embryo, and this is particularly true in the 
early stages of gestation. Growth for one or another 
cause having ceased, it is no uncommon experience 
to find the product of gestation absorbed either in 
whole or in part. The cystic mole is perhaps the most 
common form of the blighted ovum seen at an early 
stage. 

The frequency with which malformations occur is 
variously given as 156 in 10,056 births, or 1.55 per 
cent., and 232 in 8,149 births, or 2.83 per cent. 

Classification and Description. — Since the char- 
acters presented in the primary forms of the abnormal 
fetus look backward toward some previous embryo- 
logic structure, and since all degrees of variation may 
exist, from the simplest variation of a part, organ, or 
extremity to the most complete amorphism, it is 
impossible to classify monstrous embryos and fetuses 
in any consistently consecutive scheme. In the fol- 
lowing pages, therefore, an anatomical classification 
will be largely followed. 

Excessive size of the fetus, macrosomia, may appear 
before or shortly after birth, or at puberty. It 
affects the body generally and is thus, in the later 
api^earing cases, to be differentiated from gigantism 
due to acromegaly. A most striking, case of this sort 
is reported by Baldwin in which the child weighed 
twenty-three pounds at birth. Macrosomatous chil- 
dren are usually the offspring of parents of normal 
stature, but this is by no means a rule which does not 
admit of many exceptions. Speculation as to the cau- 
sation of this anomaly is, at the present stage of our 
knowledge, profitless. The same phenomenon may be 
noted in connection with one extremity or one part of 
the body, and in its lesser degrees it is by no means 
very infrequent. 

Diminutive size of the fetus may be due to impaired 
nutrition manifesting itself early in intrauterine life 
and is not an uncommon occurrence. The process 
is frequently so extreme that the fetus does not sur- 
vive and is aborted. From this is to be distinguished 
true dwarfism viicrosomia, which must also be dis- 
tinguished from smallness of the body due to rachitis, 
cretinism, and achondroplasia. True dwarfs are 
relatively few, but some of them have been well 
known. Under the name of Tom Thumb one very 
celebrated dwarf was familiar to a previous circus- 
going public; he married an almost equally diminutive 
lady by the name of Lavinia Warren. Heredity 
plays no demonstrable part in the production of 
dwarfism as most dwarfs have been the children of 
parents of normal stature and proportions. At birth 
many are normal in size, and the peculiar tendency 
of the individual manifests itself later in life. 

Abnormality of position may manifest itself in 
degrees of variation, from the displacement of a single 
viscus to the complete transposition of all of the viscera 
which latter is known as situs inversus viscerum or 
inversio viscerum. Of the complete transposition of 
the viscera there have been reported some 300 cases 
and the incidence of the abnormality bears no rela- 
tion to sex, as both are about eciually represented. 
Commonly the subject is right brained, as evidenced 
by left handedness. The explanation of this type 
of variant is usually referred to the deflection of the 
aorta to the right; the explanation of those cases in 
which the abdominal viscera are transposed while the 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



TentoloKT 



tlmraeic viscera have the normal relations, is referred 
t ' . the fact that, since the differentiation of the venous 
■vstem is of relatively late occurrence, a deviation of 
t hu abdominal veins occurring after the bases of the 
ihiiracic vessels had been establLshed, would be fol- 
lowed by a deviation of the abdominal viscera. The 
nason for the persistence of the right venous trunks 
:itid the suppression of the left primitive trunks is not 
known. 

PoLYSOMATOLS Terata. — Double or triple monsters, 
multiplicities. From the earliest times this class of 
ihiiormalities has excited the widest and most active 
piculation as to the causes which lead to monstrous 
i rmations. Up to the time of Meckel it was com- 
monly held that the double or multiple monsters were 
the result of the fusion of what were primarily two 
iir more independent embrj'os, such fusion occurring 
at an early period in the life of the embryo. Meckel 
tir-t suggested the possibility that the aberrant proc- 
1 <s might take its inception in an abnormal fission 
i if the primitive cell mass. It seems probable from 
1 he repeated investigation of the growing embryo 
under artificial conditions that the changes which 
L'ive rise to this tj-pe of monster occur before or in the 
stage of the gastruta and not later. 

The most obvious classification of the abnormal 
lituses is into monosomalous and polysomatous terata. 
The polysomatous terata may be appropriately sub- 
divided into the classes of si.-Tnmetrical and asym- 
metrical monsters, depending upon whether the con- 
tributing parts develop with a fair degree of similarity 
'ir whether one grossly outgrows the other, producing 
L'leat disparity between the contributing embrj-os. 
\\ ithin either class there occur aU degrees of variation 
t rom the complete reproduction of an individual, 
through a wide range of lesser abnormalities. When 
111 the course of development one fetus appropriates 
the greater portion of the nutrition we see an unequal 
tlfvelopment of the twins, triplets, or quadruplets. 
I'liis finds its extreme in those instances where one 
lias been killed in the process and pressed upon by 
tlic surviving and growing fetus, producing that dis- 
tnrted and flattened aborted fetus kno^^•n as fetus 
I'liliyraceus. Unioval twins or triplets may be dif- 
f rentiated from binoval twins or triplets by the fact 
t hat there is but one chorion in the former case. They 
are commonly referred to as monochorionic. In these 
cases the union is confined to the common placenta 
I which nourishes them. They are. during intrauterine 
! life, double or triple monsters within the meaning of 
' this discussion, but after birth and the severing of the 
placental circulation are completely independent. 

Plural births up to the authenticated number of 
six and the possibly apocr\-phal number of seven must 
1><- included within an enumeration of this sort. 
Ill these cases there is unquestionable evidence that 
we are dealing in many instances with monochorionic 
twins or triplets. Sommering reports a case in which 
there were four fetuses enclosed within a common 
iliorionic sac, one of them was a monster, the others 
being normal. 

Triple monsters are very rare. A case was reported 
In- Riena and Galvani in which there were two spinal 
columns distinct to their lower extremities, where 
thov were fused in the sacral region; one column 
sustained one head and the other column sustained 
two heads. There were three thoraces enclosing 
three separate hearts. The stomach was single. 
The real explanation of such a monster is impossible 
from any knowledge that we now have. 

Double-- monsters, duplicities, in which term are 
included unioval twins up to the time of birth, but 
not thereafter, include the united monsters — gemini 
conjuncti — in the description of which it is convenient 
to speak of those in which the union is anterior and 
the duplicitv posterior, in which instance the union is 
usually at or near the upper pole of the fetus; and of 



posterior union with anterior duplicity in which case 
the union is near the lower fetal poles. Middle union 
is that condition in which the fusion is from the 
umbilicus cephalad, for a variable extent. 

Anterior duplicity with fusion in the pelvic region 
occurs in two forms: pygopagus havmg anterior 
duplicity with dorsal union, the dorsal surfaces of the 
constituent parts being opposed, navels double with 
double cords converging to the common placenta, 
coccyx and sacrum common in their entirety or only 
in the lower sacral segments, spines double, digestive 
tracts separate until at or near the anus, varj-ing 
degrees of fusion in the urogenital tract; the aortsc 
have in some instances shown varying degrees of 
fusion at the lower portions, and upon one occasion 
at least the testes of both fetuses had migrated into the 
scrotum of one fetus which at autopsy contained the 
four testicles. This condition is not of nece.ssify 
incompatible with life, as has been demonstrated by 
the survival and development attained by the 
Hungarian Twins, the Bohemian Twins and the North 
Carolina Sisters which were the best known exemplars 
of the t\-pe. In ischiopagus there is anterior duplicity 
with posterior union, the opposed pubic bones being 
fused. The axes of the bodies may be the same so 
that either body may be considered an extension of 
the other from the common pelvis, or they may be so 
united as to include between the axes of the two fetuses 
a variable angle. The lower extremities may be well 
developed or two may be fused, so that there results 
a three-legged monstrosity; fusion may be complete or 
incomplete involving the thighs only. An interest- 
ing case of this sort was described by Gcmniill. Im- 
perforate anus and incomplete development of the 
lower bowel are relatively frequent and the subjects 
are not able to continue life after birth. If marked 
inequality exists between the two bodies we have an 
asymmetrical monster of this tj-pe which is called 
ischiopagus parasiticus, in which case it is not of infre- 
quent occurrence to find other serious defects in 
connection with the lesser body. Examples^ of this 
duplicity in varying degree were the Tocci Twins. 
Rita-Christina, and Marie-Rose Drouin. 

Incomplete anterior duplicity in varying degrees 
may give rise to diprosopus in which two faces are 
produced; with diprosopus triophthalmus in which the 
two mesial eyes are fused, or if the mesial eyes are 
suppressed D. diophthalmus, D. tetrophthalmus may 
be regarded as the t\-pe of this class from which the 
others are to be regarded as further deviations. The 
spinal axis in these cases shows varj-ing degrees of 
duplication. 

Dicephalus monsters are those in which the head is 
completely duplicated; thej' are usually, according to 
Piersol, due to posterior fusion. Cranu)p<igus is 
characterized by union by the heads with duplica- 
tion caudad. This union is usually by the skin and 
cranial bones, the membranes and brain being usually 
discrete. Such monsters arc usually short lived. 
Ccphalothoracopagus or syttcephalous monsters are 
those in which there is ventral or lateroventral union 
with posterior duplication leading to the development 
of a head and face toward which both contribute in 
all degrees from complete symmetry to the extremes 
of asymmetry or parasitism. Ocular and aural 
deformities are common in this class. The viscera 
may or may not participate in the fusion. 

In ntittdle union, under which fall the two classes 
Xiphopagus and Sternopagus, the union extends 
cephalad from the common umbilicus to the xiphoid 
cartilage. Union is by the integuments and at times, 
as in the case of the well-known Siamese Twins, may 
be by a bridge of hepatic tissue, the abdominal and 
thoracic cavities being otherwise discrete and with 
their normal contents. Prevost undertook to separate 
the two celebrated Brazilian twins Rosalina and 
Maria who were xiphopaga?, and succeeded to the 
extent that one survived. Stcrnopagus in which the 

131 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



union involves the manvibrium sterni which may re- 
ceive the four clavicles, is characterized by ventral 
union -nith dorsal duplication. The hearts may be 
discrete or fused although when two hearts are present 
tliey are usually invested by a common pericardium, 
tlie" product of a fusion. The thorax and diaphragm 
are common, as are usually the liver and the ab- 
dominal cavity within which the intestinal tract may 
exhibit varviiig degrees of fusion. The extremities 
are rarely "fused. The deformity is usually com- 
patible with but a few hours of extrauterine life 
because of the common occurrence of circulatory 
hypoplasia. 

" Asymmelrical mulliplicity exists in a large variety 
of cases as variants of the t>-pes indicated above. A 
formerly well-known museum "freak" Laloo was an 
instance in point, being an asymmetrical thoracopagus 
of the subclass Dipygus purasiticus. The |>arasite was 
attached from the umbilicus to the xiphoid and was 
a rudimentary body with four extremities and acoph- 
alic; the intestinal tract was incompletely developed 
and did not functionate although the urinary tract was 
independent and functionated independently. The 
parasite was incapable of independent motion and 
was not under the control of the autosite. Hirst and 
Piersol report an interesting case of Diipygus para- 
siticus in which the subject, a female duplicated below 
the third lumbar vertebra, lived, developed, and was 
eventually married, becoming pregnant upon one 
side. In" this case there was independent function 
as regards defecation and urination but parallel 
function as regards menstruation. 

Cephalic Para.sites. — Epignathus, a rudimentary 
parasite attached to the base of the skull or to the 
palate, is usually an amorphous parasite. When 
small it may be quite contained within the oral cavity, 
lludiment.ary skin and dermal appendages can be 
recognized in the tumor, and occasionally those tissues 
are more highly differentiated. Similar terata of 
the orbit have been reported by many observers, some 
of which have exhibited considerable differentiation 
of tissue. 

Encranius is a form in which the parasite lies wholly 
or partially within the skull cavity of the autosite. 
The immediate vicinity of the pituitary body is a 
frequent site for their attachment. They are usually 
amorphous masses in which, upon section study, 
can be recognized slightly differentiated tissues; 
occasionally they are more highly differentiated. 

Cervical Par,\sites. — These arise usually along the 
lines of closure of the branchial clefts and are inclusion 
cysts, containing dermal derivatives, occasionally 
teeth or portions of rudimentary bone or cartilage. 

Thoracic Parasites. — These occur as dermoid 
cysts frequently in close relation with the thymus. 

Abdominal Parasites. — These are not very common 
and when present are rarely highly differentiated; 
they are found most freijuently in relation with peri- 
toneum of the lesser sac. They may give rise to no 
trouble during life and be found at operation or upon 
the necropsy table. By far the most frequent form 
of the tumor is found as an embryonal inclusion in the 
female pelvis. 

Inclusions and other terata are found in all parts 
of the body. Sacral and genital teratomata are by 
all means the most commonly met with. The latter 
are usually cystic, covered by the skin of the autosite, 
or if not, by skin which blends with that of the host. 
The position of the original attachment may be either 
mesial or paramesial, usually the latter. "As growth 
occurs the distortion produced invariably produces 
a position -which is out of the midline. 

They are usually multilocular cysts, in the walls of 
which are found primitive bone, cartilage, or skin 
with appendages, with muscular tissue striped or 
unstriped. The sacral tumors of this class are not 

132 



necessarily incompatible with life, yet indirectly they 
lead to a great deal of trouble with the function of 
the rectum and for this reason by far the larger number 
of subjects find their way to the necropsy table in the 
course of the first eighteen months of life. Tera- 
tomata of the testes and ovaries are very common 
tumors of these glands, where they appear as dermoids, 
containing skin with its appendages, accumulated 
sebaceous material from the activity of the glands, 
occasionally bone, cartilage, or teeth. Solid teratomata 
are of considerable rarity in this region, and of still 
greater rarity are those testicular teratomata in which 
are found highly differentiated tissues. Repin reports 
a most remarkable testicidar tumor of this class in 
which there was the greater part of a skeleton with 
four limbs. 

MONOSOMATO0S Terata. — While in the foregoing 
pages ha\e been described some of those abnormali- 
ties which affect the embryo and in which one finds 
something more than one embryo in summing up the 
somatic units, in those cases now to be considered 
we are dealing with the developmental abnormalities 
arising in single units. From the standpoint of the 
student, therefore, this is the simpler class, that from 
the study of which will be derived more direct knowl- 
edge of the development of the fetus. Many of the 
abnormalities in this class, exhibiting as they do the 
characters of fetal development at the stage when the 
evolution was arrested, are very enlightening in 
matters pertaining to the course of fetal growth. 

Defects in the Cerebrospixal Axis. — If one keeps 
in mind the origin and development of the cerebro- 
spinal axis, from the neural groove, through neural 
tube, and the further differentiation into nervous tis- 
sue, membranes, and axial skeleton, it will be seen 
that if this process be arrested, either in whole or in 
part, certain typical defects will result. The extent 
of the defect depends upon the area over which the 
force acted, the degree of primitiveness of the 
deformity, and the period at which the force became 
active. 

Rhachischisis. — Failure of the processes which close 
in the spinal canal is most commonly observed in the 
lumbosacral region, but it may involve the entire 
length of the spine, holorhachischisis, or the skull with 
the spine, craniorhachischisis. The neural arches are 
undeveloped and there is extending along the po.s- 
terior aspect of the spinal region, where the promi- 
nences of the posterior spines should be noted, a longi- 
tudinal groove floored by the bodies of the vertebrae, 
upon which lies the spinal cord invested by its mem- 
branes. Very rarelj' the bodies of the vertebrse 
are cleft also, giving rise to the anterior defect known 
as rhachischisis anterior. Other malformations of a 
serious nature occur frequently with this deformity, 
making it incompatible with life. The lesser degrees 
of the deformity are usually covered in by the bony 
arches, save for some area at which there is a cystic 
protrusion of the contents of the spinal canal. These 
are styled: myelomeningocele, which occurring in the 
lumbosacral region, is by far the commonest form 
of the defect, forms a rounded cystic tumor of variable 
size, up to that of a large orange. Such a tumor is 
cystic, fluctuating, and pressure upon it diminishes 
the tumor while increasing the tension of the fon- 
tanelle. The pia-arachnoid is usually entire and 
intact, but the dura presents a defect corresponding 
in degree with the bony defect. Syringomyelocele is 
the spinal homologue of hydrocephalus interna; it is a 
dilatation of the central canal of the cord. Here 1 1n- 
thinned out and atrophic nervous tissue forms part 
of the tumor sac or cyst. Spina bifida occulta is the 
slightest degree of this deformity, in which there is 
neither cleft nor cyst visible externally, but the site 
of the deformity is usually marked by a dimple which 
may be pigmented or not and covered with hair. 
Associated disturbances of the cauda equina lead to 



I 



I 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



Tet»U>Utgj 



paralytic talipes Vhich is a common accompaniment 
of this lesion. The causation of these deformities 
has been referred to amniotic adhesions, but as an 
explanation of all cases this lacks suflBciency. 

Cbanial Defects. — Cranioschisis is the cephalic 
homologue of rhachischisis. It may coexist with 
anencephalus in wliich condition the brain is unde- 
veloped, or with eiencephalus in which the rudi- 
mentary brain is herniated beneath the integuments. 
For descriptive purposes it is divided into the sub- 
classes acranius and hemicranius. In the former the 
brain is absent or but slightly developed, the bones of 
the vault being absent or rudimentary. There may 
be associated with this condition rhachischisis and 
anencephalus. Hemierania is the lesser degree of 
the same deformity. It Ls characterized by varying 
degrees of maldevelopment of the cranial bones; there 
is frequently an associat<;d exencephalus in which the 
rudimentary brain is extruded, lying external to the 
skull and covered by the integuments and the pia- 
arachnoid. The dura is usually defective in the same 
degree as the bone. 

Cephalocele is a tumor composed of herniated brain 
substance, frequently through the sutural fissures. 
It is relatively common in the occipital reeion in the 
lambdoid suture line, and in the frontal region. 
The investments are the pia-arachnoid with the dura 
mater and the integuments. In these cases the en- 
cephalocele is probably the primarj- defect and the 
faulty bone development secondary. When this 
crindition has associated with it an increase in the 
volume of the cerebrospinal fluid the condition is 
known as hydroencephalocele. Hydrocephalus is the 
same condition arising, however, at a later period in 
intrauterine life, after the development of the cranial 
b(ines; in this case the brain is contained within the 
skull which is enlarged, with sutures gaping in pro- 
portion to the degree of distention of the ventricles. 
This latter form is by no means incompatible with 
life, although a common cause of dystocia, associated 
with death of the fetus intrapartum. Meningocele 
and hydroineningocele are those conditions without or 
with an increase in the volume of the intraventricular 
fluid, where there is a protrusion through a bony 
defect of pia-arachnoid without herniation of the 
brain. Iniencepbalus is that very rare condition in 
which encephalocele is complicated by a posterior 
spinal defect in the cervical region so that the cranial 
and cervical defects are continuous. 

Microcephalus is due primarily to a small brain 
which preser\-es its usual conformation and general 
markings but is deficient in size. The skull follows 
and grows only to such extent as will house the brain. 
The deformity is by no means incompatible with 
life, and varying degrees of true microcephalus are 
to be seen in all of our custodial institutions. Mal- 
formations of the brain itself may comprise irregu- 
larities, variations, and even suppression of convolu- 
tions, associated, when the defects are located in the 
motor area, with paralyses. They are due to develop- 
mental defects in the parts arising from the primary 
fore brain {prosencephalon), a large number of varied 
deformities of the brain being in association with 
defects in the face. The primarj- optic vesicles may 
be fused giving rise to a synophthalmus or cyclopia 
with which there is usually coexisting malformation 
in the frontonasal region. 

Defects of the Eye. — General arrest of develop- 
ment may lead to TnicrophUudmus which may be either 
unilateral or bilateral. Suppression of the eyes 
when complete is called anophlhalmiis. Fusion of the 
eyelids {symblepharon) may exist in all degrees up to 
tlie complete fusion, which entirely conceals the eye- 
ball, called crijptophlhalmus. Epicanthtis. the presence 
of a reduplication of the mucous membrane covering 
the inner canthus of the eye, is important and interest- 



ing as being a persistence of the nictitating membrane 
of the birds. 

Facial axd cervical iiALroRjiATioxs are in large 
degree due to the persistence of the branchial clefts 
of early embryonic life. Aprnsnpus is practically an 
absence of the face, the clefts remaining widely and 
irregularly open. Harelip, chiloscldsis, is a common 
and relatively minor failure of fusion and may be 
complete into the nares or incomplete in all degrees. 
It may be unilateral or bilateral. It is frequently, 
associated with cleft palate, laHomaxillary cleft. Its 
position may be either lateral or mesial. With the 
mesial cleft there is usually defective development of 
the nasal septum and anterior displacement of the 
intermaxilla. Microstomum and mncrostomum arc 
due to defect in the closing in of the lateral processes. 
This may lead to a wide range of variation from 
excessive size of the mouth down to complete absence 
of the mouth or astomum. Of rare occurrence are 
defects of the tongue varj-ing from anterior cleft, 
producing bifid tongue, to almost complete reduplica- 
tion of the member. Since the form and contour of 
the external ear is the result of the proportionate 
gron-th of and fusion of six separate tissue masses 
great variation in ears is common and normal. Dis- 
parity in the growth of the contributing masses leads 
to a wide range of aural deformities varing from com- 
plete absence of the external ear to various clefts of 
the ear and distortions. These aural defects are 
frequently as.sociated with development of the struc- 
tures arising from the first and second branchial 
clefts. 

Incomplete closure of the fissures with persistence 
of part of the tract, or inclusions along the course of 
the tract, lead to a variety of branchial cysts or fistula 
in the region of the neck. In connection with the 
cer\-ical spine arise variations springing from the 
failure of the suppression of vestiges commonly found 
in the normal fetus, giving rise to more or less com- 
plete cervical ribs which are frequently bilateral. 
If bilateral there is usually a difference in the develop- 
ment upon the two sides. 

THOR.VX -VST) .\bdomen'. — Failure of complete mesial 
union of the abdominal and thoracic plates gives rise 
to a number of defects in the parietes, of which the 
most common are those which appear in and about the 
umbilicus, where the congenital umbilical hernia is 
the commonest and the least grave. Omphalocele 
or hernia into the cord is a condition in which prior 
to birth abdominal contents have been forced into 
the cord after having passed through the incompletely 
closed umbUical ring. Such a hernia is invested, 
from within outward, by peritoneum, preperitoneal 
areolar tissue with fat, and close to the body by skin, 
more remote from tlie body by the amniotic covering 
of the cord. Portions of the solid viscera as well as 
intestine have been found in such sacs. Major degrees 
of this defect result in complete or extensive Ihora- 
coschisis, thoracoga^troschisis, or gastroschisis, result- 
ing in a practical evisceration of the subject. It is 
more common, however, to find this in an incomplete 
form as ectopia of a viscus. The most frequent form, 
occurring below the umbilicus, is due to a faulty 
development of the urachal tract and varies from 
the incomplete urachal Jisluln to the complete form in 
which there is an urinary fistula, a grosser degree of 
which is found in ectopia vesiccF, in which there is a 
variable degree of deficiency in the fundus of the 
bladder, with fusion of the bladder to the abdominal 
parietes. The cause of these defects has been referred 
to early abnormal adhesion between the vitelline duct 
and the chorion. 

Malformations of the diaphragm may vary from 
complete absence to small defects which appear usu- 
ally in the line of fusion of the anterior and posterior 
leaves and at or near the esophageal opening. In 
these the pleura and peritoneum are continuous, 

133 



REFERENCE HANDBOOK OF THE MEDIC^VL SCIENCES 



reminiscent of the primitive celomic cavity of the 
iirimitive vertebrates. Such defects give passage to 
diaphragmatic herniie in which varying amounts 
of tlic abdominal contents are extruded into the 
pleural cavities. Secondary displacements of the 
heart and lungs occur as pressure effects. Tins 
deformitv sliould be borne in mind as an mfrequent 
cause of postnatal cvanosis. Dislocation of the heart 
downwarfl throvigh the diaphragmatic defect the 
reverse of the process just noted, has occurred, but is 
' excessive! v rare. . x • 

The esophagus is occasionally absent in part or 
replaced by an uncanalized cord. As a minor variant 
of this extreme deformitv, atresia may occur at any 
level Bifid esophagus, due to partial duplication, 
has been observed. Tlie slomach is rarely deformed 
save in connection with other extreme deformities 
elsewhere in the body. Variations in size occur in 
the direction both of small and of large stomachs. 
Atresia of the fijlnTus has been observed rarely. In 
the intcslinal tract jjcrsistence of parts of the omphalo- 
mesenteric duct, described as Meckel's diverticulum, 
constitutes the most common malformation, being 
present in about two per cent, of all subjects. When 
present it usually occurs in the last four feet of the 
small intestine, is" usually from two to two and a half 
inches in length, but may extend to the umbilicus. 
When patent throughout, it is the cause ofumbilico- 
inti-stinal fistula. Atresia of the intestine at various 
levels lias been reported, but extensive defects in the 
intestine are usually found in association with very 
profound defects elsewhere in the body. Defects 
of the large bowel are much more freciuent and may 
consist in atresia at the anus or atresia of the rectum 
with a blind sac of rectum at some distance from the 
skin. Various fusions of the rectum with the lower 
urogenital tract occur in which they are fused into a 
cloaca or common outlet. The liver and spleen are 
seldom the seat of malformation save in connection 
with extensive maldevelopment of the intestinal tract. 
The spleen is occasionally absent and there are several 
reported cases of supernumerary spleens, among them 
one by Albrecht in which there was absence of the 
.spleen, but some 400 small bodies scattered throughout 
the peritoneal cavity which proved upon section to be 
true splenic tissue. The suprarenals may be diminu- 
tive and occasionally wanting or there may be present 
.small accessory bodies. 

Of the deformities occurring in the respiratory 
tract the nasal deformities have been indicated under 
facial clefts. Variations in the size of the larynx are 
common, and fusions of the cartilages and super- 
numerary cart ilages are common. Atresia of the larynx 
is rare and total absence has been noted only in connec- 
tion with other grave defects. The trachea has been 
absent, the bronchial bifurcation proceeding directly 
from the larynx. All lesser degrees of shortened 
trachea with high bifurcation of the bronchi have 
existed. Congenital constriction and atresia have 
occurred at all levels and variations in the number of 
the cartilaginous rings are very common. In those 
cases where the left lung is trilobate tliere is a third 
bronchus present, and eparterial in position. This 
variation in the number of lobes in the left lung is 
the principal variation in the lungs, other variations 
in form being very rare. 

Heart and Circulatory System. — Congenital 
anomalies of the heart are very common, but un- 
fortunately large numbers of the cases never reacli 
the necropsy table, so that our best studies do not 
completely represent the relatively large number of 
deviations from the normal in this important system. 
Recalling the development of the heart from the 
jirimitive straight tube, through the S-shaped tube, 
later further differentiated into auricular and ven- 
tricular portions, and the final differentiation with the 
formation of the intraventricular septa, and remem- 
bering that the rotation of the heart progresses pari 

134 



passu with this differentiation, it -R-Ul be seen that 
arrest at any stage may determine the persistence 
of a fetal structure, which in turn may lead to very 
interesting secondary changes in the viscera whose 
condition and position are determined by the rela- 
tion of tlie heart or of those of the great vessels which 
come off from it and develop with it. Thus an ab- 
normal selection of the arches retained or suppressed 
in the process of cardiogenesis will serve to explain 
many of the variations herein enumerated. The inter- 
auricular septum is that part most commonly <l<'fect- 
ive; rarely it is absent giving rise to a threo-cliam- 
bered heart; when so absent there are usually present 
in the same subject other serious defects in other 
systems. Some degree of patency of the foramen 
ovale is very commonly met with and constitutes the 
most common variety of congenital heart defect. 
Less frequent in occurrence is a defect in the inter- 
ventricular septum, usually in the pars membranacea, 
tliat portion last closed in, and when present this is 
usually associated with an abnormality of the septum 
between the aorta and the pulmonary artery. 

Associated with this or quite independent of it 
there may be persistence of the Botallian duct or 
ductus arteriosus in varying degree. Probably the 
lesser degrees of patent ductus arteriosus are rather 
more common than is indicated in the text-books. 
Malformations of the great vessels arise from abnormal 
persistence of the primitive arches. The aorta may 
occasionally be seen coming off from the right ventricle 
with the pulmonary artery springing from the left. 
Persistence of the primitive double aorta may lead to 
various degrees of doubling of that vessel. The 
semilunar valves are frequently fused, reducing the 
segments to two in number, or the leaflets may be 
cleft, in which case there have been reported as many 
as five segments. Stenosis of the pulmonary artery 
or of the aorta may coexist with stenosis of the conus 
arteriosus, in which case it is due to primary hypo- 
plasia of the conus. Or the pulmonary artery or the 
aorta may be narrowed while the other is allotted more 
than the normal share of the truncus arteriosus, this 
is due when present to an aberrant position of the 
septum which partitions the truncus. The auriculo- 
vcntricular valves may present congenital stenosis, or 
variation in the number of valve flaps. The entire 
arterial and venous systems are subject to variation, 
as is the lymphatic system, throughout their extent; 
these constitute too large a list to be catalogued in 
the space of this review. Transposition of the lieart, 
associated with some degree of transposition of the 
other viscera, of which it is in large degree the pre- 
cursor, is due to the persistence of the fourth right 
arch and the suppression of the fourth left arch, as the 
basis upon which the aorta is developed. In thoracic 
cleft — thoracoschisis — the heart may be in a state of 
ectopia, a rare condition, and incompatible with life. 
Doubling of the heart through imperfect fusion is a 
rare anomaly and is due to an arrest in the process of 
heart development. 

Malformation in the urogenital system may 
include: absence of both kidneys, disparity in the size 
of the kidneys, absence of one kidney, fusion of the 
kidneys in various forms, and persistence of the fetal 
lobulations; with this may occur double ureter from 
one or both kidneys or fusion of the ureters at various 
levels with single entrance into the bladder. The 
renal pelvis may show similar variation, being not 
infrequently partially duplicated. Rarely aberrant 
termination of the ureters may, in the male, lead to 
implantation into the urinarj^ tract below the bladder 
or into the rectum, and in the female into the rectum, 
vagina, or the uterus. Both classes of aberrant im- 
plantation are reminiscent of the cloacal type of 
excretory system. The bladder, as indicated under 
abdominal deformities, may suffer ectopia or fistula 
due to failure of the urachus to close. Below- it may 



I 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



participate in the deformities of the external genitalia. 
Such inferior deficiency of the bladder is due to failure 
of the parietes to close and fuse in the midline. Com- 
plete absence of the bladder with implantation of 
the ureters into the rectum is rare. Rarely, also, 
the bladder is divided into two portions the upper 
being a persistence of the allantoic portion. 

The urethra in either sex may be occasionally lack- 
ing. More commonly it is defective, particularly in 
the male, where, by faultj' development and fusion of 
the genital folds, it may be deficient along the dorsum 
constituting an epispadias. With extreme degrees 
of epispadias there may be defective fusion of the 
pubic bones and faulty development of the bladder. 
Hypospadias in varying degrees is a very common 
deformity among males, varying from a mere de- 
ficiency in the floor of the urethra at the glans penis to 
complete absence of the floor and cleft scrotum. It 
is due to failure upon the part of the genital folds to 
fuse and develop in the median line. 

Malformations of the Sexual Organs. — Absence of 
the testicles in the male is rare, malposition is rather 
common. Cryplorchism or undescended testicle is 
common in the intermediate form in which the gland 
is retained, undescended, in the inguinal canal, and 
very rare in its primary lumbar position. Defects in 
portions of the duct apparatus are found, and verj' 
rarely a real doubling of the gland. Absence of both 
ovaries is rare, absence of one or hj-poplasia of one or 
both is rather common and frequently associated 
with rudimentary uterus or tubes. Displacement is 
common and rarely the ovary is found in the inguinal 
canal. Absence of the Fallopian tubes is rare; un- 
equal development of the two is very common. 
Malformations of the uterus are due to arrests in the 
development of that organ from the ducts of Miiller. 
The.se may find their expression as undeveloped small 
uterus, septate uterus, with or without septate vagina, 
double uterus or bicornate uterus in which the lower 
zone is fused >but the upper discrete. Uterus didelphys 
is that condition in which the duplicity is carried 
through uterus and vagina. 

The vagina being part of the tract developed also 
from the ducts of Miiller is subject to the same de- 
velopmental variations as the uterus. It may be 
septate in whole or in part or double. Duplicity of 
the vagina may coexist with the same condition of 
the uterus or independently of the uterus. The 
vagina may vary in length and in caliber, and in rare 
instances may be absent. As noted above it may 
receive the ureters or by deficiency in the rectovaginal 
septum be in part fused with the lower rectum, form- 
ing a cloaca. 

In both sexes the external genitalia are not differ- 
entiated until the third month. Failure of the de- 
velopmental forces at any period after this time leads 
to the production of organs which more or less closely 
resemble those of the other sex, depending upon the 
time at which the arrest has occurred. In the male 
the deformities of hypospadias and epispadias have 
been adverted to; other deformities may occur, such 
as diphallus or doubling of the organ in any degree 
with occasional duplication of the urethra and in rare 
cases the presence of separate canals for the urinary 
and the seminal passages. In the female tlie external 
genitals may very rarely be absent, more freciuently 
very rudimentary. Hj'pertrophy of the clitoris or 
of one or both labia minora arc more common in 
some degree. The most striking variations in this 
system are those in which the sex differentiation 
is incomplete and gives rise to the appearance of 
hermaphroditism. The expression "appearance of 
hermaphroditism" is used advisedly, for true herma- 
phroditism in which there are present in the same 
body glands which are histologically demonstrated 
1o be ovary and testicle are very rare indeed. If 
l)resent true hermaphroditism could exist in three 
forms: bilateral, unilateral, and lateral. Bilateral 



hermaphroditism would be that condition where there 
exist upon both sides either paired organs (testicle 
and ovary) or a composite gland histologically present- 
ing the characters of both. The number of instances 
in which examination has been carried to convincing 
conclusion in this cla.ss of ca.se,s is very few. Unilateral 
hermaphroditism is the condition in which upon one 
side there is a testicle or ovarj- and upon the other a 
duplicated gland which presents the characters of 
testicle and ovary. Of this class there have been a 
few clearly authenticated examples. Lateral her- 
maphroditism is characterized by the presence upon 
each side of a gland, upon one side ovary upon the 
other testicle. This class includes the largest num- 
ber of true hermaphrodites, but the number of cases 
in which the histological proof is complete is very 
small. The number of ca.scs of false hermaphroditism 
is verj' much larger. The ultimate classification of 
the subject rests upon the character of the sexual 
ghind. Male false hermapliroditism is classified a-s 
internal, external, and complete. In the external 
form the incomplete fusion of the genital folds and 
ridges gives to the external genitals the appearance 
of the female organs. The general conformation of 
the body, presence of fat, and absence of normal hair 
distribution enhance the feminine appearance. In 
the internal forms, in connection with normal or 
external genitals closely approximating normal, there 
are found rudimentary vagina and uterus due to modi- 
fication of the sinus pocularis. In the complete form 
both externally and internally the organs resemble 
more or less clo.sely those of the female t>-pe. Uterus, 
vagina, and tubes may be present in varying degrees 
of incomplete development, the vagina communicat- 
ing with a small and rudimentary vestibule beneath 
the root of a somewhat rudimentarj- penis, or enlarged 
clitoris. The testes are usually undescended. 

Female pseudo-hermaphrodifism is more rare than 
the masculine type. The internal is that form in 
which, with normally formed external organs, there 
coexists in the broad ligaments some trace of a primi- 
tive testicle or epididymis. The external is that in 
which there is excessive fusion of the genital folds 
so that the organs resemble the male t_%-pe, with hyper- 
trophied clitoris resembling a penis with hj-pospadias, 
and fused labia majora resembling cleft scrotum. 
The ovary has in these cases been found in the canal of 
Nuck, the homologue of the inguinal canal in the male. 
In the complete form, both external and internal 
organs resemble in some degree the male type. It is a 
rare type of deformity, and the final determination of 
sex ititra vitam is impossible. The literature of the 
subject contains many interesting studies based 
upon these subjects. 

.\b.vok.\lalities of the Extremities. — These de- 
fects, varying from complete suppression and intrau- 
terine amputation to reduplication of parts, occur and 
will be briefly noted: Amelits is that condition in 
which both arms and botli lower extremities are ab- 
sent or represented by the merest rudiment-s. Abra- 
chius or Apu-s indicates the absence of arms or feet. 
Monobrachius or jnonnpus is the absence of one foot 
or arm the other being possibly normally developed. 
In peromelus all of the limbs are defective. In phoco- 
meliui the upper portion of the extremity is suppressed 
or rudimentary the distal (portion being more or less 
well developed. Perobrachiiis and pcropu^ a condi- 
tion in which the upper and lower extremities re- 
spectively are the seat of suppression of the proximal 
portion of the member. Micromitus denotes small 
extremities, microbrachius small arms, mirro;>ii.s. small 
lower extremities. Sifmp"^. si/mmctus are defects in 
which there is varj'ing degree of fusion of the lower 
extremities, being designated, according to whether 
the feet are absent, single, or double called apua, 
moiwpus, or dipus. Syndactylism is the congenital 
fusion of two or more tingers or toes and may vary 

135 



Teratology 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



from web fingers to fusion of the ])halanges. Fused 
fingers and the production of supernumerary digits, 
in complete or rudimentary degree, appear to be 
traits whicli are transmitted from one generation to 
another in certain families. As yet the studies 
undertaken have not demonstrated the laws under 
which this occurs. In other cases the deformity is 
the result of intrauterine accident. 

Congenital dislocations occur as the result of the 
action of the same forces which cause many of the 
deformities above numerated. Tlie hip-joint is that 
most commonly affected. The knees and ankles with 
the elbows more rarely. 

Malformations of the skin and of the dermal append- 
ages may occur in any degree, and are usually varia- 
tions of the processes which normally involve the 
skin and its derivatives. They consist in local or 
generalized variations in pigmentation, keratosis, 
growth of hair, as well as variations of the cutaneous 
glands. The variations of the mammary glands are 
the most striking. The mammary glands are modi- 
fied sweat glands, appearing along two bilateral lines 
extending from the region of the fore limbs along the 
ventral surface of the body toward the inguinal region. 
This is the so-called "milk line." Along this line in 
the human subject occur occasional variations in the 
number and location of the mammae. There may be 
reduplication of the nipple or the development of one 
or more supernumerary glands in the course of this 
tract. More rarely rudimentary mamma; are met 
with in other locations. The writer has seen a twenty- 
year-old male medical student who presented himself 
at the hospital with what he thought was a suppur- 
ating axillary Ij'mph node. Upon dissection and 
histological examination it proved to be a super- 
numerary mamma in lactation. This occurred in an 
anterior e.xtension of the milk line which is not un- 
common. More rarely posterior extensions have been 
noted upon the thigh, and it is reported that one of 
the causes of trouble between Anne Boleyn and Henry 
the Eighth was that she had a supernumerary nipple 
upon the buttock. Edw.\rd M. Colie, Jr. 



Teratoma. — .\ teratoma is a tumor-like growth 
characterized essentially by the fact that the tissue- 
formation of which it is composed does not occur 
normally in the affected region, or at least not during 
that period of bodily development in which it pre- 
sents itself. Such a gro-n-th may consist of a single 
tissue, or may be represented by a cyst (simple teratoid 
tumor or cyst) ; but more frequently it is made of several 
tissues arising from one or more than one of the germ 
layers (mixed tumor, bidermoma, tridermoma). 

To the more complicated forms the term teratoma 
is often applied in a more narrow sense, while those 
highly complex growths which contain tissues de- 
rived from all three of the germ layers are known as 
embryoid tmnors or embryomata. Teratomata com- 
posed of tissue-formations which are out of place in 
the region where found are known as heterotopous; 
those composed of tissue occurring in a given region 
at a time when it should not normally be found there 
are known as heterochronous. Teratomas are chiefly 
congenital in origin, are to be referred to disturbance's 
of development. The tissue-formation composing the 
teratoma takes its origin either from the anlage of the 
individual affected (monogerminal, endogenous, or au- 
lochthonous teratoma), or from the anlage of a second 
individual (higerminal or ectogenous teratoma, fetus in 
felji). All possible transitions exist from the simplest 
mixed tumors up to forms represent ing the development 
of an organ, system of organs, or even a half or total 
embryo. Further, either a sarcomatous or a carcino- 
matous proliferation may develop within a teratoma, 
and the gro^\-th thereby assume the characteristics of a 
malignant tumor (malignant or blastomatous teratoma). 

The genetic relationship of the various tissues con- 

136 



stituting the teratoma is a problem of the greatest 
interest. Usually they have a close genetic relation- 
ship in that they represent chfferent products of differ- 
entiation of a common indifferent germinal anlage. 
Inasmuch as these anlagen are out of their normal 
tissue-relation and are developing under abnormal con- 
ditions they cannot be regarded as normal but must 
possess a pathological quality. Under such abnormal 
conditions embryonal ceUs may differentiate along 
quite different lines than the normal. They usually 
show a greater potentiality than under normal condi- 
tions. Since the normal potentiality of cells is greater 
than their prospective value under abnormal condi- 
tions the resulting tissues may be very different from 
those resulting from normal differentiations. 

According to their structure, teratomata may bo 
divided into the following varieties: 



nple teratoid tumo 
nple teratoid cysts. 



Tridermo 

(embryoid tu 
Malignant or blasto 



Ectodermat | Epid^?moi.l. 

Mesodermal. 

( Entodermal. 

Complex teratomata and teratoid cyst:? 

id embryomata). 

tous teratomata. 



I. Simple Ter.\toid TtjMORS. — In this class are 
placed both heterotopous and heterochronous tissue- 
formations of simple structure, consisting of but a 
single variety of tissue, or at most of but a few forms 
of tissue. For the greater part, they consist of hetero- 
topous tissue-proliferations which have their origin 
in misplaced or persistent fetal anlage. The.v may 
occur in any part of the body, but are found most 
frequently in certain regions. The most common 
tumors of this class are the hypernephroma (kidney, 
kidney region, liver,_ etc.), rhabdomyoma or rhab- 
domyosarcoma (kidney, testicles, vas deferens, heart, 
vagina, cervix, bladder, etc.), chondroma (salivary 
glands, mamma, skin, testicles, etc.), chondromyxoma 
(salivary and lacrymal glands, mamnup, testicles), 
adenomyxoma (mamma), adenosarcoma (kidney), 
adenomyoma (uterus, broad ligament), leiomyoma 
(kidney), osteoma (m^iscles, skin, mamma, etc.), 
lipoma (meninges), and the tumor-like formations 
found along the vertebral column (coccygeal and 
lumbosacral lipomata, myolipoma, and the tumors 
of this region which contain nervous elements). 

The occurrence of tissue-formations in regions in 
which such tissue-elements are not normally found 
may be explained by the assumption of a misplace- 
ment of tissue anlage, or of tissue at a later stage of 
development, or of the persistence of undifferentiated 
cells, which possess the power of producing different 
forms of tissue. In general, it may be said that the 
simple teratoid tumors correspond in their structure 
with the tissue-differentiations occurring normally in 
the region in which they arise. Every part of the 
body practically has its corresponding mixed tumor, 
which in its structure harmonizes with the normal 
differentiation of the tissues and organs of that region. 
Thus, for example, the mixed tumors of the salivary 
and lacrymal glands contain cartilage, bone, myxo- 
matous tissue, connective tissue, epidermis, and 
glandular tissue, corresponding to their origin from 
ectodermal and mesenchymal anlage of the head or 
mouth region (branchiomas). In the mixed tumors of 
the mamma myxomatous tissue, cartilage, epidermis, 
and gland tissue are found, corresponding to their origin 
from ectodermal and mesenchymal or mesodermal 
anlage. The mixed tumors of the kidney and kidney 
region which contain striped muscle, cartilage, etc., 
arise from anlage of the myotome and middle plate. 
Those of the vagina and cervix arise from the anlage de- 
rived from the myotome and sclerotome, or from that 
portion of the mesoderm lying posterior to the kidney. 
It is probable that the teratoid gro'n'ths of this region 
arc dependent upon the development of the Wolffian 
duct, as they are situated for the greater part in the 
region of the ducts of Gartner. The fatty tumors 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



Teratoma 



(•ontaining epithelial and nervous structures, whioh 
are found along the spinal column, chiefly in the lumbo- 
sacral and coccygeal regions, are due to misplace- 
ments of anlage or tissue caused by defective develop- 
ment of the vertebral arches, and are to be classed 
with the various forms of the malformation known 
as spina bifida occulta. Similar tumors are also found 
in the cranium. In the changes following a hernial 
Ijrotrusion of the spinal cord and lucninges in spina 
bifida both adipose tissue and striped muscle may be 
misplaced into the spinal canal. Transposition of 
adipose tissue, muscle, cartilage, ependymal tissue, 
and neurogha is not infrequently seen in these mal- 
formations. The lipomata of the cerebral meninges 
are likewise to be explained in part as due to a tran.s- 
piisition of adipo.se tissue following or attendant upon 
:i defective development of the cranium (sclerotome, 
nr[)hrotome). 

Though the great majority of the simple teratoid 
tumors are to be regarded as heterotopous prolifera- 
f ions of tissue arising from autochthonous fetal anlage. 
it is also possible that some may be due to bigerminal 
inclusions, in which only one or "but a few of the tissues 
of the parasitic twin persist. The parent cells of the 
simple teratoid growths in either case remain latent 
or grow slowly until through some exciting factor 
a more active proliferation is set up. At firstthe 
Tuisplaced anlage increases through a proliferation of 
undifferentiated cells, but with changing conditions 
of growth a portion of the cells becomes differentiated, 
and there are formed mature tissues, which may con- 
liiuie to proliferate in their differentiated form. The 
I'auses of active proliferation of Latent anlage are 
unknown; inflammation or irritation or atrophy of 
the affected part may play the role of exciting factor. 
That the early stages of growth consist in the forma- 
tion of undifferentiated cells is shown by the fact th.at 
tlio younger portions of the tumor are alw'ays com- 
posed of such cells. These may predominate to such 
an extent that the growth resembles a sarcoma 
(adenosarcoma, cyslosarcoma, carcinosarcoma, rhab- 
domyosarcoma). Further, the fact th.at the different 
tissues con.stituting the growth (cartilage, striped 
muscle, etc.), occur in all parts of the tumor can be 
explained only by the assumption of a Later differen- 
tiation of cells arising through the proliferation of the 
\mdifferentiated cells of the misplaced or persistent 
anlage. Moreover, the f.act th.at the metastases of 
the mixed tumors may contain all the tissue found in 
tlie primary points to the metastasis of undifferen- 
tiatefl cells, which later become differentiated. 

The simple teratoid tumors of the salivary gl.ands, 
mamma, kidney, uterus, etc., though placed in the 
same tumor class because of their analogous origin 
frtun cells of the ectoderm, mesenchym or mesoderm, 
nevertheless show great differences in their m.anner 
of growth, malignancy, etc. The mixed tumors of 
t lie parotid are very slow in development, they produce 
no metastases, and are relatively benign in character; 
t hose of the kidney, uterus, and vagina may grow 
very rapidly, set up metastases, and assume the 
character of very malign.ant tumors. The met.astascs 
arise from the transportation of undifferentiated 
cells from the primary tumor; through the differentia- 
tion of these the daughter tumor comes to contain the 
same tissues as the parent tumor. However, a 
metastasis of more highly differenti.ated cells m.ay 
occur, and the tumor arising from these may present 
a less complicated structure than the primary. The 
metastases of the mixed tumors, like those of sar- 
coma, are hematogenous, the lymph glands being 
rarely involved. The differences in malignancy be- 
tween the mixed tumors of the salivary gland.s_ and 
those of the kidney cannot at present be explained. 
The latter present the clinical characteristics of 
sarcoma, occur more frequently in early life, grow 
r.apidly, and arc usu.ally f.at.al;" the former develop 
in later life, grow slowly, and are only rarely fatal. 



A secondary carcinomatous or sarcomatous prolifera- 
tion may, however, develop within the benign tera- 
toid growths of the lacrymal and salivary glands, 
mamma, etc. The hypernephroma is also frequently 
the scat of a proliferation so active as to assume 
clinically the characteristics of malignancy. 

All the teratoid tumors are to be regarded as con- 
genital tumorSj even when developing very late in 
life. The persistence of undifferentiated anlage in a 
latent condition for years has physiological analogues 
in the late development of the" beard, pubic hair, 
wisdom teeth, etc. Nevertheless, some authors do not 
accept a congenital origin for all of these growths and 
as.sign to some of them a development from endothe- 
lium, or explain their mixed structure as arising from a 
metaplasia of other tLssues, some going so far as to 
assume a metaplasia of unstriped muscle into striped, 
or even of connective tissue into smooth muscle. 
In some of the simple teratoid tumors, particularly 
those of the salivary and lacrymal glands, the pro- 
liferation of the endothelium is often the predomi- 
nating feature of the growth, and from a purely 
structural point of view ju.stiiies the designation of 
endothelioma or myxochondroma endothcliale, as the 
case may be. The endot helial nat ure of the cell strands 
and cords of the salivary gland tumors is a much 
disputed point. In the consideration of these growths 
it mu.st be borne in mind, however, that the prolifer- 
ating endothelium arises from the tumor anlage, and 
not from the endothelium proper of the region 
concerned. 

2. Simple Ter.\toid Cysts. — The simple teratoid 
cysts may be divided into three classes: the ectodermal, 
mesodermal, and entodermal cysts. 

(o) Ectodermal Cysts. — These arise from the mis- 
placement or transplantation of ectodermal anlage. 
They may consist of cavities lined only by stratified 
squamous epithelium, without hairs or other skin 
structures {epidermoid cysts, epidermcnds), or of cysts 
whose walls contain hairs, glands, subcutaneous fat, 
etc, presenting all the characteristics of skin (der- 
moid cysts, dermoids, dermatocysts). In the case of 
the former only epidermal anlagcs are transplanted; 
in the case of the Latter, embryonal dermal tissue mvist 
also be transplanted. These growths are of frequent 
occurrence; they vary in size from that of a pea to that 
of an orange. Both epidermoids and dermoids occur 
chiefly in the skin and subcutaneous tissues as cv.sts 
filled with a pultaceous material, resembling athero- 
mata or sebaceous cv.sts caused by retention of the 
secretion of sebaceous glands. In the epidermoids 
the cyst contents consist of desquamated hornv cells 
alone; in the dermoids hairs are found in addition to 
the desquamated colls. The hairs are of a light or 
reddish color. Fatty degeneration or liquefaction 
of the cyst contents may occur, and cholesterin plates 
may be present in large numbers. .\t other times the 
contents are tirmer, dry, and present a pearly trans- 
lucency or luster. The cyst contents may also 
become calcified. 

Epidermoids. — These are found most frequently in 
the cranium, neck, thoracic cavity, mcdi.a.stinum, 
pelvic cellular tissue, coccygeal region, and perineum, 
and more rarely in the jieritoneal cavity. In the 
cranium they occur in the meninges or in the hypophy- 
sis in the form of the tumors known as cholcsteatomnia 
or pearl tumors. These are spherical or nodular 
tumors, varying in size from th.at of a pea to that of 
an orange, and are distinguished by their glistening 
satiny white surface. Microscopically, they consist 
chiefly of thin, non-nucleated, scale-like colls arranged 
in closely packed lamina', the central portions of which 
may present a pultaceous disintegration and enclose 
pl.ates of cholesterin. .\ccording to Bo.stroni they 
are invariably situated at some point upon the pia, 
which at the site of the growth is covered with 
stratified squamous colls. These become piled up 

137 



REFERENCE HANDBOOK OF THE MEDICAL SCIENCES 



into a tumor-like mass, and in the course of years form 
the horny lamina-, which constitute the gro\rth. The 
neighboring brain tissue and the arachnoid are not 
concerned in the formation of the horny cells. The 
dura and arachnoid may cover the tumor. Portions 
of the cholesteatoma may become separatedfroin the 
main mass and be misplaced into the brain tissue. 
At the base of the brain cholesteatomata may be 
found in the neighborhood of the olfactory lobe, tuber 
cincreum, corpus callosum, pons, medulla oblongata, 
cerebellum, and choroid plexus. They are seen but 
rarely in the meninges of the spinal cord. The intra- 
cranial epidermoids arise most probably from epider- 
malgerms which have become misplaced into the anlage 
of the pia at a very early stage of development. 
According to Bostrom, this takes place in the time 
between the closure of the medullary canal and the 
separation of the secondary vesicle of the fore-brain 
from the fore-brain or tween-brain, and the separation 
of the after-brain \-csicle from the hind-brain (fourth 
to fifth week). The merliastinal dermoids probably 
arise from disturbances of development of the thymus. 
Those occurring in the neck arise from remains 
either of the branchial clefts or of the ductus thyreo- 
glossus. The cholesteatomata of the middle ear 
may in part be explained as due to misplaced epi- 
dermal germs. The ejjidermoids of the pelvic cellu- 
lar tissue are the result of epithelial inshoots from 
the perineum. 

Dermoids. — The simple dermoid cysts or dermoids 
possess walls showing all the characteristics of skin — 
that is, papilla?, hair follicles, hairs, sweat, and seba- 
ceous glands, and often also subcutaneous fat. The 
cyst contents are similar to those of the epidermoids, 
but contain in addition hairs. The dermoids are 
found in the same regions as the epidermoids, and are 
to be explained as due to transplantations of dermal 
anlage at the same time as epidermal. 

Both the epidermoids and dermoids may be the seat 
of development of a squamous-celled cancer. This 
event occurs most frequently in the neck region 
(branchiogenic and subcutaneous carcinoma). 

(6) Mesodermal and Entodefmal Cysts. — Cysts aris- 
ing from misplaced or persistent entodermal or meso- 
dermal anlage are of relatively frequent occurrence. 
They are characterized by a lining of columnar cells, 
■which are often ciliated; and they form cysts varying 
in size from that of a pinhead to that of a m.an's head. 
They are found most frequently in the broad ligament 
and tubes, less often in the peritoneal cavity, intes- 
tine, in the neighborhood of the trachea and bronchi, 
in the lungs, pleura, tongue, neck, liver, kidneys, etc. 
They owe their origin to the persistence of fetal glands 
or ducts, or to misplaced entodermal or mesodermal 
epithelial anlage. Those found in the uterine wall, 
broad ligament, and tubes arise from remains of the 
Wolffian body and the duct of Gartner; those of the 
cervix, portio vaginalis, vagina, and hymen arise 
from remains of the latter. In the peritoneal cavity 
and abdominal wall they may arise from snared-off 
and persistent portions of the intestine (enierocysts), or 
from portions of the urachus {urachus cysts). In the 
liver and kidney they may arise from portions of the 
gland tubules constricted during the period of develop- 
ment {ailenocysls, cystic liver and kidney). In the neck 
remains of the internal branchial clefts, in the posterior 
portion of the tongue the remains of the thyreoglossal 
duct, or of epithelial buds and glands developing 
from the same, in the esophagus and respiratory tract 
snared-off portions of the intestinal canal or air pas- 
sages, or remains of the communication between the 
aUmentary tract and air pas.sages, may form the anlage 
for the development of such cysts. Cysts lined with 
columnar cells may arise in the central nervous system 
or its immediate neighborhood (myelocysts). These 
are seen most frequently in the lumbosacral and 
coccygeal regions. In the abdominal wall cysts lined 
with columnar cells may arise from remains of the 

138 



omphalomesenteric duct (umbilical cysts, omphalo- 
mesenteric cysts). 

The origin of entodermal and mesodermal cysts 
can usually be determined from the anatomical rela- 
tions and "their structure. When the misplacement 
of the tissue is but slight, and when the anatomical 
structure still shows clearly the character of the 
mother tissue the genesis of the growth may be easily 
determined. The size of these cysts varies from that 
of a pinhead to that of a man's head. Their clinical 
importance is dependent upon their location, size, 
and the character of the secondary changes occurring 
in them. The cyst wall may become inflamed or 
undergo degeneration, or through an active epithelial 
proliferation either adenoma or carcinoma may develop. 
Adenomata, cystadenomata, and adenomyomata de- 
velop frequently from remains of the Wolffian body. 
In rare cases an adenoma may develop from the re- 
mains of the omphalomesenteric duct (umbilical 
adenoma). Adenomata and cylindrical-celled car- 
cinomata may develop from snared-off portions of 
intestine, or of kidney and liver tubules. 

3. Complex Teratoid Cysts and Tumors. — In this 
group fall those growths representing all the germ- 
layers, the so-called tridermomas. These show a ten- 
dency to form organs, systems, and even embryo-like 
structures. The teratoid cysts and tumors of compli- 
cated structure are found in the same regions as the 
simple teratoid growths, but occur most frequently in 
the sexual glands, and in the region of the coccyx. 
Their complicated structure is shown by the presence, 
either in the cyst wall or in the solid growth, of a great 
variety of tissues : squamous and columnar epithelium, 
ciliated epithelium, dermal structures, nerve tissues, 
cartilage, bone, striped and unstriped muscle, fat 
tissues, gland tissues, etc. They may also contain 
tissue of a carcinomatous or sarcomatous nature. The 
different tissue elements are sometimes of embryonal 
character. Such unripe or undifferentiated forms are 
potential autonomous blastomas and eventually may 
show characteristics of maUgnaney in the form of 
sarcoma. At other times they resemble fully matured 
tissue. They are sometimes found in orderly arrange- 
ment, suggesting the arrangement of tissues and 
organs found in the normal human body. In other 
cases the cells may show hypoplasia, secondary atro- 
phy, loss of proportion, etc. Organs and systems are 
frequently repeated in great numbers. In many cases, 
however, there is no definite grouping of tissue-ele- 
ments beyond that of the germ layers, ectodermal 
tissues being grouped together, mesodermal together, 
etc. The cysts may be lined with squamous, simple 
columnar, or ciliated epithelium, and in the first case 
may contain hair. Teeth and bone are of frequent 
occurrence in