v»1 CORNELL UNIVERSITY. ilosmell THE I. 3P(ouaer 5Tibr*»rg THE GIFT OF ROSWELL P. FLOWER FOR THE USE OF " THE N. Y. STATE VETERINARY COLLEGE 1897 CORNELL UNIVERSITY LIBRARY 3 1924 104 225 325 The original of this book is in the Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924104225325 A Reference Handbook OF THE MEDICAL SCIENCES EMBRACING THE ENTIRE RANGE OP SCIENTIFIC AND PRACTICAL MEDICINE AND ~4 ALLIED SCIENCE i v % IBRARY. BY VARIOUS WRITERS ,■£ * .£ -t A NEW EDITION, COMPLETELY REVISED AND REWRITTEN EDITED BY ALBERT H. BUCK, M.D. New York City VOLUME YII ILLUSTEATED BY CHROMOLITHOGRAPHS AND SIX HUNDRED AND EIGHTY- EIGHT HALE-TONE AND WOOD ENGRAVINGS NEW YORK WILLIAM WOOD AND COMPANY MDCCCCIV T Copyright, 1903, BY WILLIAM WOOD AND COMPANY PUBLISHERS' PRINTING COMPANY 32 AND 34 LAFAYETTE PLACE, NEW YORK LIST OF CONTRIBUTORS TO VOLUME VII. SAMUEL W. ABBOTT, M.D.. Newton Centre, Mass. Secretary of State Board of Health of Massachusetts. CHARLES WARRENNE ALLEN, M.D.. New York, N. Y. Professor of Dermatology, New York Post-Graduate Medical School; Consulting Dermatologist to the Randall's Island Hospitals. JAMES RAE ARNEILL, M.D Denver, Col. Associate Professor of Medicine, University of Colo- rado, Denver, Col. ; formerly Instructor in Clinical Medicine, University of Michigan. ISAAC E. ATKINSON, M.D Baltimore, Md. Formerly Professor of Therapeutics and Clinical Med- icine, Medical Department of the University of Maryland. JAMES B. BAIRD, M.D Atlanta, Ga. Professor of Clinical Medicine, Southern Medical Col- lege ; Attending Physician, Grady Hospital, Atlanta, Ga. FRANK BAKER, M.D., Ph.D Washington, D. C. Professor of Anatomy, Medical Department, George- town University, Washington, D. C. ; Superintend- ent, National Zoological Park, Smithsonian Institu- tion. FREDERICK AMOS BALDWIN, M.D. .Ann Arbor, Mich. Assistant in Pathology, Medical Department, Univer- sity of Michigan. CHARLES EDWARD BANKS, M.D. . .Chicago, III. Surgeon and Medical Purveyor, United States Marine Hospital Service. LEWELLYS FRANKLIN BARKER, M.B. (Toronto), Chicago, III. Professor of Anatomy, Medical Department, Univer- sity of Chicago; formerly Associate Professor of Anatomy in the Johns Hopkins Universit}'. DONALD McLEAN BARSTOW, M.D... New York, N. Y. Clinical Assistant, Department of Medicine, Vanderbilt Clinic, College of Physicians and Surgeons, Colum- bia University. WALTER ARTHUR BASTEDO, Ph. G., M.D. .New York, N. Y. Instructor in Materia Medica and Therapeutics, Col- lege of Physicians and Surgeons, Columbia Univer- sity ; formerly Torrey Club Lecturer on Botany at the New York College of Pharmacy. ROBERT RUSSEL BENSLEY, M.D. (Toronto), Chi- cago, III. Assistant Professor of Anatomy, University of Chi- cago. HENRY W. BERG, M.D New York, N. Y. Attending Physician to the Willard Parker and River- side Hospitals; Adjunct Attending Physician to Mount Sinai Hospital. HENRY WALD BETTMANN, M.D Cincinnati, Ohio. Pathologist, City Hospital of Cincinnati ; formerly Pro- fessor of Medicine, Cincinnati College of Medicine and Surgery. ROBERT PAYNE BIGELOW, Ph.D. .Boston, Mass. Instructor in Biology, Massachusetts Institute of Tech- nology. W. P. BOLLES, M.D Boston, Mass. Professor of Materia Medica and Botany, Emeritus, Massachusetts College of Pharmacy ; Attending Sur- geon, Boston City Hospital. DAVID BOVAIRD, Jr., M.D New York, N. Y. Tutor in General Medicine, College of Physicians and Surgeons, Columbia University; Associate Physician to the Presbyterian Hospital; Pathologist to the Foundling Hospital. L. DUNCAN BULKLEY, M.D ...New York, N. Y. Attending Physician, Skin and Cancer Hospital ; Der- matologist, Randall's Island Hospitals. WILLIAM NORTON BULLARD, M.D Boston, Mass. Physician, Department of Diseases of the Nervous System, Boston City Hospital ; Consulting Neurolo- gist, Carney Hospital; Neurologist, the Children's Hospital. FRANK BULLER, M.D Montreal, Canada. Professor of Ophthalmology and Otology, Medical De- partment, McGill University. RICHARD CLARK CABOT, M.D. .. .Boston, Mass. Assistant in Clinical Medicine, Harvard University Medical School; Physician to Out-Patients, Massa- chusetts General Hospital. WILLIAM JEPHTHA CALVEBT, M.D. .Columbia, Mo. Assistant Professor of Internal Medicine, Missouri State University, Columbia, Mo. ; formerly Assistant Sur- geon, United States Army, Manila, Philippine Islands. DONALD M. CAMMANN, M.D... New York, N. Y. H. W. CLARK, Esq Boston, Mass." Chemist in Charge of Experimental Station and Labo- ratories at Lawrence, Mass. SOLOMON SOLIS COHEN, M. D. . Philadelphia, Pa. Lecturer on Clinical Medicine, Jefferson Medical Col- lege; Attending Physician, Philadelphia and Rush Hospitals. WILLIAM T. COUNCILMAN, M.D. . .Boston, Mass. Shattuck Professor of Pathological Anatomy, Harvard University Medical School. JOSEPH WILLIAM COURTNEY, M.D Boston, Mass. Assistant Physician for Diseases of the Nervous Sys- tem, Boston City Hospital. DAVID MURRAY COWIE, M.D..Ann Arbor, Mich. First Assistant in Internal Medicine, Medical' Depart- ment, University of Michigan. JAMES K. CROOK, M.D New York, N. Y. Adjunct Professor of Clinical Medicine and Phj'sical Diagnosis, New York Post-Graduate Medical School; Attending Physician, New York Post-Graduate Hos- pital. Ill LIST OF CONTRIBUTORS TO VOLUME VII. EDWARD CURTIS, M.D New York, N. Y. Emeritus Professor of Materia Medica and Therapeu- tics, College of Physicians and Surgeons, Columbia University. JOHN CHALMERS Da COSTA, M.D.. Philadelphia, Pa. Professor of the Principles of Surgery and of Clinical Surgery, Jefferson Medical College; Attending Sur- geon, Philadelphia Hospital; Consulting Surgeon, St. Joseph's Hospital, Philadelphia. THOMAS DARLINGTON, M.D. .Kingsbridge, New York, N. Y. Attending Physician, New York Foundling Hospital, New York, and St. John's Riverside Hospital, Yon- kers, N. Y. D. BRYSON DELAVAN, M.D New York, N. Y. Professor of Laryngology, New York Polyclinic; Consulting Laryngologist, General Memorial Hospi- tal and Hospital for Ruptured and Crippled, New York. JOHN DOUGLAS, M.D New York, N. Y. Attending Surgeon, University and Bellevue Medical College Clinic; Assistant Attending Surgeon, St. Luke's Hospital, Out-Patient Department. THEODORE DUNHAM, M.D New York, N. Y. Adjunct Professor of Surgery, New York Post-Grad- uate Medical School; Attending Surgeon, Post- Graduate Hospital (Babies' Wards). WILLIAM A. EDWARDS, M.D Coronado, Cal. Attending Physician, Coronado Hospital. J. HAVEN EMERSON, M.D New York, N. Y. MARTIN F. ENGMAN, M.D St. Louis, Mo. Chief of Dermatological Clinic, Medical Department, Washington University, St. Louis, Mo. ; Dermatolo- gist, St. Louis City Hospital. AUGUSTUS A. ESHNER, M.D. . .Philadelphia, Pa. Professor of Clinical Medicine, Philadelphia Poly- clinic; Attending Physician, Philadelphia Hospital; Attending Physician, Hospital for Diseases of the Lungs at Chestnut Hill. PAUL F. EVE, M.D Nashville, Tenn. Professor of Principles and Practice of Surgery and of Clinical Surgery, Medical Department, University of Tennessee. WILLIAM HASTY FLINT, M.D. . .Santa Barbara, Cal. EDWARD MILTON FOOTE, M.D New York, N. Y. Instructor in Minor Surgery, College of Physicians and Surgeons, Columbia University; Visiting Surgeon, City Hospital, New York. EUGENE FOSTER, M.D Augusta, Ga. Professor of Principles and Practice of Medicine and State Medicine, Medical Department, University of Georgia. JOSEPH FRAENKEL, M.D New York, N. Y. Instructor in Nervous Diseases, Cornell University Medical School; Neurologist to the City Hospital; Physician to the Montefiore Home, New York. ALBERT HENRY FREIBERG, M.D. .. .Cincinnati, Ohio. Professor of Orthopaedic Surgery, Medical Department, University of Cincinnati; Orthopaedic Surgeon to the Cincinnati, Presbyterian, and Jewish Hospitals, Cincinnati. JAMES M. FRENCH, M.D Cincinnati, Ohio. Lecturer on the Theory and Practice of MediciDe, Medical College of Ohio; Attending Physician, St. Mary's Hospital; Consulting Physician, St. Francis Hospital for Incurables. F. MORLEY FRY, M.D Montreal, Canada. Clinical Assistant, Royal Victoria Hospital ; Assistant Physician,. Montreal Foundling and Sick Baby Hos- pital. FREDERIC R. GREEN, M.D Chicago, III. Head Demonstrator of Anatomy and Instructor in Osteology, Northwestern University Medical School, Chicago. JOHN GREEN, M.D St. Louis, Mo. Special Professor of Ophthalmology, Medical Depart- ment, Washington University, St. Louis. WILLIAM DAVID HAGGARD, M.D. . ..Nashville, Tenn. Professor of Gynaecology and Diseases of Children, Medical Department, University of Tennessee ; Gynae- cologist to the Nashville Hospital. WINFIELD SCOTT HALL, M.D Chicago, III. Professor of Physiology, Northwestern University Medical School, Chicago. ALICE HAMILTON, M.D Chicago, III. Professor of Pathology, Women's Medical College of Northwestern University, Chicago. HENRY FAUNTLEROY HARRIS, M. D .. Atlanta, Ga. Professor of Pathology and Bacteriology, College of Physicians and Surgeons, Atlanta, Ga. MILTON B. HARTZELL., M.D. .Philadelphia, Pa. Instructor in Dermatology, Medical Department, Uni- versity of Pennsylvania ; Dermatologist to the Meth- odist Hospital of Philadelphia and to the Philadel- phia Hospital. WILLIAM BARKER HILLS, M.D. .. .Boston, Mass. Associate Professor of Chemistry, Harvard University Medical School. OSCAR H. HOLDER, M.D New York, N. Y. Instructor in Dermatology, the University and Belle- vue Hospital Medical College ; Attending Dermatol- ogist, Out-Patient Department, Bellevue Hospital. WILLIAM H. HOWELL, Ph.D., M.D.. ..Baltimore Md. Professor of Physiology, Medical Department, Johns Hopkins University, Baltimore. JAMES NEVINS HYDE, M.D Chicago, III. Professor of Skin and Venereal Diseases, Rush Medical College ; Attending Surgeon, Michael Reese, Presby- terian, and Augustana Hospitals, Chicago. EDWARD JACKSON, M.D Denver, Col. Emeritus Professor of Diseases of the Eye, Philadel- phia Polyclinic; Ophthalmologist to the Mercy Hos- pital, Philadelphia. GEORGE THOMAS JACKSON, M.D... New York N. Y. Instructor in Dermatology and Chief of Clinic, College of Physicians and Surgeons, Columbia University; Consulting Dermatologist, the Presbyterian Hospital and the New York Infirmary for Women and Chil- dren. GEORGE T. KEMP, Ph.D., M.D. . .Champaign, III. Professor of Physiology, University of Illinois. EDWARD L. KEYES, Jr., Ph.D., M.D. New York N. Y. Lecturer on Genito-Urinary Surgery, New York Poly- clinic Hospital ; Special Lecturer on Genito-Urinary Diseases, Georgetown University, District of Colum- bia ; Assistant Visiting Surgeon, St. Vincent's Hos- pital, New York. CARL KOLLER, M.D New York N. Y. IV LIST OF CONTRIBUTORS TO VOLUME VII. MAYNARD LADD, M.D Boston, Mass. Assistant in Diseases of Children, Harvard University Medical School; Assistant Physician to the Chil- dren's Hospital; Assistant Physician to the West End Nursery and Infants' Hospital, Boston. DANIEL SMITH LAMB, M.D. , .Washington, D. C. Pathologist, Army Medical Museum at Washington, . D. C. ; Professor of Anatomy, Medical Department, Howard University, Washington, D. C. RALPH CLINTON LARRABEE, M.D Boston, Mass. Assistant in Histology, Harvard University Medical School; Physician to Out-Patients, Boston City Hos- pital. HENRY LEFFMANN, M.D Philadelphia, Pa. Professor of Chemistry and Toxicology, Women's Med- ical College of Pennsylvania; Pathological Chemist to Jefferson Medical College Hospital; Honorary Professor of Chemistry, Wagner Free Institute of Science. WILLIAM M. LESZYNSKY, M.D.. New York, N. Y- Neurologist to the Demilt Dispensary and the German Poliklinik ; Consulting Neurologist to the Manhattan Eye and Ear Hospital. ALFRED HAMILTON LEVINGS, M.D.. Milwaukee, Wis. Professor of the Principles and Practice of Surgery and of Clinical Surgery, Wisconsin College of Phy- sicians and Surgeons ; Surgeon to Milwaukee County and St. Joseph's Hospitals; Consulting Surgeon to Emergency Hospital and to Milwaukee Hospital for Acute and Chronic Insane. ROBERT W. LOVETT, M.D Boston, Mass. Assistant in Orthopaedic Surgery, Harvard University Medical School; Surgeon to Infants' Hospital ; Sur- geon to the Peabody Home for Crippled Children; Assistant Surgeon to Children's Hospital, Boston. ALEXANDER GEORGE McADIE, M.A San Francisco, Cal. Professor of Meteorology, United States Weather Bureau. ERNEST LEWIS McEWEN, M.S., M.D. .. .Chicago, III. Associate Instructor in Dermatology, Rush Medical College, Chicago. FRANKLIN P. MALL, M.D Baltimore, Md. Professor of Anatomy, Johns Hopkins University. FRANK BURR MALLORY, M.D Boston, Mass. Associate Professor of Pathology, Harvard University Medical School. HARRY T. MARSHALL, M.D Baltimore, Md. Instructor in Pathology, Johns Hopkins Hospital, Bal- timore. CHARLES F. MARTIN, M.D. . .Montreal, Canada. Assistant Professor of Medicine and Clinical Medicine, McGill University ; Assistant Physician, Royal Vic- toria Hospital, Montreal. LAFAYETTE BENEDICT MENDEL, Ph.D.... New Haven, Conn. Professor of Physiological Chemistry, Yale University. HERBERT C. MOFFITT, M.D.. San Francisco, Cal. Lecturer on Theory and Practice of Medicine, Medical Department, University of California. BENJAMIN MOORE, M.A. .. .Liverpool, England. Professor of Biochemistry, University College, Liver- pool, England ; Formerly Professor of Physiology, Yale University, New Haven, Conn. WILLIAM S. MORROW, M.D. ..Montreal, Canada. Lecturer in Physiology, McGill University; Clinical Assistant in Medicine, Royal Victoria Hospital, Mon- treal. ALBERT GEORGE NICHOLLS, M.D.. ..Montreal, Canada. Lecturer in Pathology, McGill University; Assistant Pathologist to the Royal Victoria Hospital, Montreal. SAMUEL NICKLES, M.D Cincinnati, Ohio. Emeritus Professor of Materia Medica and Therapeu- tics, Medical College of Ohio. ALBERT P. OHLMACHER, M.D..Gallipolis, Ohio. Superintendent of the Ohio Hospital for Epileptics and Director of the Pathological Laboratory. WILLIAM OLDRIGHT, M.D Toronto, Canada. Professor of Hygiene and Associate Professor of Clini- cal Surgery, University of Toronto; Surgeon to St. Michael's Hospital; Member of the Provincial Board of Health of Ontario. B. ONUF (ONUFROWICZ), M.D Sonyea, N. Y. Pathologist to the Sonyea Colony of Epileptics. EDWARD OSGOOD OTIS, M.D Boston, Mass. Professor of Pulmonary Diseases and Climatology, Tufts College Medical School; Visiting Physician, Free Home for Consumptives, Boston; Physician to the Department of Pulmonary Tuberculosis, Boston Dispensary. ROSWELL PARK, M.D Buffalo, N. Y. Professor of Surgery. Medical Department, University of Buffalo; Surgeon to the Buffalo General Hospital. WILLIAM PI. PARK, M.D New York, N. Y. Associate Professor of Bacteriology and Hygiene, The University and Bellevue Hospital Medical College. GEORGE A. PIERSOL, M.D Philadelphia, Pa. Professor of Anatomy, Medical Department, Univer- sit}' of Pennsylvania. LEWIS STEPHEN PILCHER, M.D., LL.D. .Brook- lyn, N. Y. Surgeon to the Methodist Episcopal Hospital and to the German Hospital in Brooklyn. PAUL MONROE PILCHER, M.D.. Brooklyn, N. Y. Assistant Attending Surgeon to the Methodist Episco- pal Hospital, Brooklyn, N. Y. N. J. PONCE de LEON, M.D Havana, Cuba. Deputy Health Officer of the Port of Havana, Cuba; formerly Instructor in Medicine, New York Post- Graduate Medical School. WILLIAM HENRY POTTER, Esq.. ..Boston, Mass. Assistant Professor of Operative Dentistry, Harvard University. WILLIAM ALLEN PUSEY, M.D Chicago, III. Professor of Dermatology, Medical Department, Uni- versity of Illinois. LEOPOLD PUTZEL, M.D New York, N. Y. MAJOR CHARLES RICHARD .... Zamboanga, Min- danao, Philippine Islands. Surgeon, United States Army. HENRY H. RUSBY, M.D Newark, N. J. Professor of Botany, Physiology, and Materia Medica. New York College of Pharmacy ; Professor of Ma- teria Medica, University and Bellevue Hospital Med- ical College, New York. BERN HARD SACHS, M.D New York, N. Y. Consulting Surgeon, Mount Sinai Hospital, New York. LIST OF CONTRIBUTORS TO VOLUME VII. EDWARD WILLIAM SCHAUFFLER, M.D.. Kansas City, Mo. Professor of Principles and Practice of Medicine and of Clinical Medicine, Kansas City Medical College. R. J. E. SCOTT., M.D New Youk, N. Y. Attending Physician, Bellevue Hospital, Out-Patient Department; Gynaecologist, Demilt Dispensary, New York. GEORGE B. SHATTUCK, M.D Boston, Mass. Visiting Physician, the Boston City Hospital. FRANCIS J. SHEPHERD, M.D.. Montreal, Canada. Professor of Anatomy. and Lecturer on Operative Sur- gery, McGill University ; Senior Surgeon to the Mon- treal General Hospital. DANIEL KERFOOT SHUTE, M. D .... Washington, D. C. Professor of Anatomy, Medical Department of the Columbian University, Washington, D. C. BEAUMONT SMALL, M.D Ottawa, Canada. Attending Physician, St. Luke's General Hospital, Ottawa; Consulting Physician, The Children's Hos- pital, Ottawa; Late Examiner in Materia Medica, College of Physicians and Surgeons, Ontario. ERNEST ELLSWORTH SMITH, M.D., Ph.D. .New York, N. Y. Pathologist to Trinity Hospital, New York City, and St. John's Riverside Hospital, Yonkers, N. Y. ; Con- sulting Pathologist to the Somerset Hospital, Somer- ville, N. J. M. ALLEN STARR, M. D New York, N. Y. Professor of Diseases of the Mind and Nervous System, College of Physicians and Surgeons, Columbia Uni- versity; Consulting Physician, Presbyterian, St. Vincent's and St. Mary's Hospitals and the New York Eye and Ear Infirmary. BRIG. -GEN. GEORGE M. STERNBERG .. Washing- ton, D. C. Late Surgeon-General, United States Army. ISRAEL STRAUSS, M.D New York, N. Y. Assistant in Neuro-Histology, Cornell University Med- ical School; Adjunct Attending Physician, Hospital for Incurables, Almshouse, Blackwell's Island. MERVIN T. SUDLER, M.D., Ph.D... .Ithaca, N. Y. Instructor in Anatomy in Johns Hopkins University, Baltimore, and in the Cornell University Medical College, Ithaca, N. Y. EDWARD W. TAYLOR, M.D Boston, Mass. Instructor in Neuropathology, Harvard University Medical School. AUGUSTUS THORNDIKE, M.D Boston, Mass. Visiting Surgeon, Good Samaritan Hospital and West End Infant Hospital; Junior Assistant Surgeon, Children's Hospital, Boston. BENJAMIN T. TILTON, M.D. .. .New York, N. Y. Instructor in Surgery, Cornell University Medical Col- lege; Assistant Visiting Surgeon, Bellevue Hospital; Visiting Surgeon, Lincoln Hospital, New York City. ERNEST EDWARD TYZZER, M.D. .Boston, Mass. Austin Teaching Fellow in Histology and Embryol- ogy, Harvard University Medical School. HENRY SWIFT UPSON, M.D. . .Cleveland, Ohio. Professor of Diseases of the Nervous System, Western Reserve Medical School ; Attending Physician to the Lakeside Hospital. FERD. C. VALENTINE, M.D New York, N. Y. FREDERICK H. VERHOEFF, M.D. . .Boston, Mass. Pathologist, Massachusetts Charitable Eye and Ear Infirmary; Assistant in Pathology, Harvard Uni- versity Medical School ; Assistant Ophthalmic Sur- geon, Carney Hospital, Boston. JAMES J. WALSH, M.D., Ph.D., LL.D..New York, N. Y. Lecturer on General Medicine, New York Polyclinic. HENRY BALDWIN WARD, Ph.D.. .Lincoln, Neb. Dean of the College of Medicine and Professor of Zoology, The University of Nebraska. ALDRED SCOTT WARTHIN, M.D Ann Abbor, Mich. Professor of Pathology and Director of the Pathologi- cal Laboratory in the University of Michigan, Ann Arbor, Mich. HARRY GIDEON WELLS, M.D Chicago, III. Associate in Pathology, University of Chicago. ROYAL WHITMAN, M.D New York, N. Y. Chief of Clinic and Instructor in Orthopaedic Surgery, College of Physicians and Surgeons, Columbia Uni- versity. CHARLES F. WITHINGTON, M.D. . .Boston, Mass. Instructor in Clinical Medicine, Harvard University Medical School. RUDOLPH A. WITTHAUS, M.D. .New York, N. Y. Professor of Chemistry, Physics, and Toxicology, Cor- nell University Medical College in New York City. EDWARD 8. WOOD, M.D Boston, Mass. Professor of Chemistry, Harvard University Medical School. PHILIP ZENNER, M.D Cincinnati, Ohio. Clinical Lecturer on Diseases of the Nervous System, Medical College of Ohio. VI A REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. Saccharin. Saccliaromycosls. SACCHARIN or GLUSIDE — (Benzoyl-mlphonimide). A coal-tar product, a derivative of toluene, with the for- mula C e H 4 (CO)(80 2 )NH. It occurs as a light, white pow- der, odorless but with an intensely sweet taste. It is very slightly soluble in cold water, more so in boiling water, alcohol, and glycerin. Its solution gives an acid reaction, and it forms sweet salts with alkaloids and metals. Its property of combining with alkaloids is taken advantage of to supply quinine and other bitter sub- stances in a more palatable form. The insolubility of gluside is overcome by combining it with soda to form a soda salt which is very soluble. It may be prepared by dissolving one hundred parts in water and neutraliz- ing the solution with bicarbonate of soda and evaporat- ing to dryness; this forms one hundred and thirteen parts of soluble gluside or saccharin. It has been placed in the British Pharmacopoeia under the title of Glucidum. Excepting in its sweetening power, gluside is not allied to sugar in any way. It does not affect polarized light, it lacks the essential character of sugar to produce alco- hol by fermentation, and when administered does not increase the production of sugar in the system. It is this latter quality that renders it of value in the treatment of diabetes, where it is desired to avoid the use of sugar as far as possible. Gluside is two hundred and eighty times as sweet as sugar, and if it is remembered that an ordinary lump of sugar ranges from 150 to 300 grains, it is very evident that one-half to one grain will be an equivalent. Its disadvantages are the distaste that the patients are liable to have for it after using it for a time, and the dry, acrid sensation which it produces in the pharynx . In medicines, it may also be used to replace sugar and syrup for the purpose of rendering them palatable, one grain with a six- ounce mixture furnishing sweetness equal to one ounce of ordinary syrup. To facilitate dispensing, the follow- ing solutions are prepared : Liquor Gtlusidi. — From the "National Formulary "of the American Pharmaceutical Association. Gluside, 512 grains; bicarbonate of sodium, 240 grains; alcohol, 4 fluidounces; water, sufficient to produce 16 fluidounces. Each drachm represents four grains of gluside. Elixir Qlusidi. — From the "Unofficial Formulary" of the British Pharmaceutical Conference. ' Gluside, 480 grains; bicarbonate of sodium, 240 grains; rectified spirit, 2i fluidounces; distilled water, a sufficiency. Rub the gluside and the bicarbonate of sodium in a mor- tar, with half a pint of distilled water gradually added. When dissolved, add the spirit, filter and wash the filter with sufficient distilled water to make one pint. Each drachm represents three grains. Saccharin may be given freely, as it is devoid of toxic action. In some cases re- ported its prolonged use has produced symptoms of gas- tric disturbance with indigestion, but this rarely occurs. As much as seventy -five grains have been given at one dose without producing any ill effect. It is, however, advisable that not more than twenty -five grains daily be administered. Gluside possesses antiseptic properties in common with other coal-tar derivatives, and for this reason it has been suggested as a remedy in many diseases. It has been Vol. VII.— 1 used in pulmonary phthisis, acute articular rheumatism, scarlatina, intestinal catarrh, cystitis, and a number of other disorders in which its antiseptic action might prove of service. Of these, cystitis is the only one in which any satisfactory results have been obtained. In this con- dition it is administered internally and renders the urine antiseptic during its excretion. When there are pus and an alkaline reaction, this is rapidly overcome, and the urine becomes clear and normal in character; the change in the urine being accompanied by a corresponding im- provement in the mucous membrane of the bladder. Three grains, in divided doses, daily, is the quantity rec- ommended, and this is to be continued for a prolonged period. The bladder may also be irrigated at the same time. Beaumont Small. SACCHAROMYCOSIS.— Our knowledge of pathogenic yeasts and of the pathological conditions produced by them is at present but slight ; and the unsatisfactory state of the classification and terminology of the blastomycetes has led to much confusion. Inasmuch as the blastomy- cetes are usually divided into various genera, Sacchdro- myces, O'idium, Manilla, ■ etc. , the term saccharomycogis should be limited to the pathological conditions produced by the yeasts which are included under the Saccharomy- cetes, viz., those characterized by their power to ferment sugar and form alcohol, of which Saccliaromyces cerevisix may be taken as the type. But few observations of such pathogenic yeasts have been made. The most important contributions to this subject are those of Busse and Curtis. In 1895 Busse obtained pathogenic yeasts from a wom- an suffering with a peculiar cystic tumor of the tibia, which on microscopical examination presented the ap- pearance of a sarcomatous-like granulation tissue con- taining giant cells. From the viscid fluid obtained from the tumor yeast-like fungi were cultivated. Pure cult- ures of the yeast were pathogenic for mice and rabbits, giving rise, when injected into the animal, to nodules of chronic granulation tissue, and leading to the formation of metastatic miliary nodules in the brain, kidneys, and lungs. The organism grew well on ordinary media, at ordinary and incubator temperatures, forming white, non-characteristic growths, which did not liquefy gela- tin. On special media to which malt extract was added the growth was more abundant, and on potato and other media, grayish or black cultures were obtained. Acid media seemed especially to favor its growth. Glucose media were fermented with the production of alcohol and carbonic dioxide. Reproduction took place by bud- ding exclusively. The patient died thirteen months after the appearance of the tibial tumor, and at autopsy nu- merous foci of disease.containing the yeast in great abund- ance, were found in the lungs, kidney, and spleen, some reaching the size of an apple. The yeasts were also found in a small corneal vesicle. Microscopically these lesions resembled those of a chronic inflammatory proc- ess with caseous and fatty degeneration ; in these lesions the yeasts were found in great numbers, lying singly or in colonies. In the next year a similar case was reported by Curtis, Sacro-IUac Disease. Sage. REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. who obtained a yeast, Saccharomyces subcutaneus twme- faciens, from myxomatous tumors appearing in a young man, beneath the skin of the neck and thigh, and also from a large ulcer of the loin. Microscopically these tumors resembled myxosarcoma. Both in and between the tumor cells yeasts were found in large numbers. These were easily cultivated, and caused sugar to ferment with the production of alcohol. Dogs, rabbits, rats, and mice were susceptible to inoculation, a chronic inflamma- tion and proliferation being produced at the site of injection. In old cultures endosporous division was seen. Corselli and Frisco report a case of saccharomycosis in which " sarcomatous " nodules were found in the omentum and mesentery. . The chylous ascitic fluid obtained by ex- ploratory puncture during life contained the yeast fungi, which were cultivated and found to be pathogenic for dogs, rabbits t and guinea-pigs. Pathogenic yeast fungi have also been found in cases of chronic catarrh of the uterine cervix (Colfe and Buschke), and in proliferative catarrh of the nasal mucosa (Busse). Saccharomycetes have also been reported as occurring in the secretion from a case of peculiar inflam- mation of the conjunctiva and cornea; in phalangitis ; in the purulent discharge of otitis media ; in the blood, sputum, and urine of a case of typhus (Calmette) ; in a pseudomembranous angina in a patient suffering from typhoid (Froisier and Achalme). Saccharomyces ruber has been regarded as the cause of a house epidemic of intestinal catarrh, the infection occurring through the contamination of milk. This same yeast was isolated by Casagrandi from diabetic urine. When inoculated into animals it produced small nodules containing pus. A variety closely related to, if not identical with Saccharo- myces cerevisias, has been found in the coating of the tongue, in diarrhoeal stools, in vomited material, and in diabetic urine. Inasmuch as the organism of thrush is classed by some writers as a yeast — Saccharomyces albicans — the lesions of thrush would be considered under the head of saccharo- mycosis. (See Mouth, Diseases of, in The Appendix.) Pathogenic saccharomycetes have been found in a number of diseased conditions of the lower animals. Saccharomyces niger (Maff uci and Sirleo). has been regarded as the cause of a pulmonary affection which occurs in guinea-pigs and resembles tuberculous pneumonia, and of an intestinal condition in the same animal, character- ized by ulceration of the mucosa and enlargement of the mesenteric glands. Saccharomyces guttulatus has been described by Casagrandi and Buscalioni as occurring in the intestinal tract of mammals. These authors isolated it from the stomach and intestines of rabbits. It causes glucose to ferment with the formation of alcohol and it inverts saccharose. "When inoculated into rabbits, guinea- pigs, and rats it produces nodules containing pus, and finally death. Sanfelice obtained from swine a non- liquefying, gas-producing yeast — Saccharomyces granu- lomatosus — pathogenic only for swine, and producing granulomatous nodules, containing giant cells, in which the parasites often become calcined. The experimental " pseudo-tumors " produced by the injection of blasto- mycetes have also been described under the head of sac- charomycosis. The various pathogenic organisms described as saccha- romycetes and the lesions ascribed to them can hold but a tentative position in pathology, until more definite light has been thrown upon the subject by additional observation and experimentation. Aid/red Scott Warthin. SACRO-ILIAC DISEASE.— Tuberculous disease of the sacro-iliac articulation is uncommon and extremely so in childhood. The symptoms are pain, limping, weakness, and change in attitude. The pain is referred to the side of the pelvis or radiates over the buttock or thigh. It is increased by jars, by turning the body suddenly, some- times by coughing or laughing. A peculiar feeling of insecurity and weakness about the pelvis and hip-joint is a common symptom. The trunk is inclined toward the sound limb, as a result of which the pelvis is lowered on the affected side. The leg seems longer than its fel- low, and the patient walks with a peculiar awkward limp. In the early stage of the disease there is no deformity of the limb, but if a pelvic abscess forms the thigh may become flexed. Locally there may be sensitiveness to direct pressure on the articulation and swelling in the neighborhood of the disease, although this is usually a late symptom. Pain is induced by lateral pressure on the pelvis or by any manipulation that disturbs the artic- ulation. Abscess finally appears in the majority of cases. It may be extra- or intrapelvic. In the latter case it may present itself above the crest of the ilium. It may pass through the sciatic notch or appear in the ischiorectal fossa, or it may break into the rectum. Sacroiliac disease may be mistaken for sciatica or for disease of the hip or spine. The freedom of motion and the absence of muscular spasm when the pelvis is fixed, if examination is carefully conducted, should exclude both the one and the other, although the pain on lateral pressure, which is described as the most characteristic symptom, may be simulated closely by primary acetab- ular disease. The attitude is similar to that of sciatica, but the symptoms of local sensitiveness to jars and to manipulation are much more marked. Treatment. — The local treatment consists in protect- ing the sensitive parts- from injury, and the removal of the disease if it be possible. In the ambulatory treatment a plaster spica bandage or a double Thomas hip brace combined with the use of crutches may be indicated, but in most instances a broad, strong pelvic girdle, which may be drawn tightly about the pelvis, will be most efficient. If motion of the spine causes discomfort, this girdle may be reinforced by some form of spinal brace. Constitu- tional treatment is of course indicated as in other forms of tuberculous disease. The prognosis is unfavorable, probably because the majority of the cases are in adults, a class in which the prognosis of any tuberculous disease is more serious than in childhood. In addition there is usually the complica- tion of an infected and burrowing abscess. Injury of the Sacro-lliac Articulation. — All the symp- toms described as characteristic of the tuberculous dis- ease of the sacro-iliac articulation may be induced by strain or other injuries of this region, and doubtless by other affections than tuberculosis, such, for example, as rheumatism or infectious arthritis. Such causes are perhaps more common in early life than is tuberculous disease. The principles of treatment (that is, rest and protection of the sensitive part by the pelvic girdle or other support) are indicated. If this treatment is efficient the cure is usually rapid and com- plete. Royal Whitman. SAEGERSTOWN MINERAL SPRINGS (formerly Eu- reka Springs). — Crawford County, Pennsylvania. Post-Opfioe. — Saegerstown. Hotel and sanatorium. Access. — -ViS main line of the Erie Railroad to Saegers- town, six miles east of Meadville. Saegerstown is situated on the historic Venango River, now called French Creek, in a beautiful and healthful valley, 1,200 feet above the ocean level. The scenery here is of a charming rural character, and the surround- ings offer excellent opportunities for fishing, rowing, hunting, driving, bicycling, etc. The sanatorium is a large and commodious building, having all the modern conveniences of a hotel combined with facilities for the care and treatment of invalids. The grounds are taste- fully laid out, and include spaces for croquet, lawn- tennis, and other games. A billiard-room and bowling alley have been fitted up for the guests of the house, and during the busy season an orchestra will furnish music in the evening hours. The hotel is open the entire year. There are two mineral springs at Saegerstown, issuing from a bed of rock about three hundred feet deep. An analysis, made in 1896 by W. H. Dean, analytical chemist 2 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Sacro-Iliac Disease. Sage. of Wilkesbarre, showed the following chemical ingredi- ents of one of the springs: One United States gallon contains (solids): Sodium chloride, gr. 7.46; sodium sulphate, gr. 0.62; potassium sulphate, gr. 0.22; calcium sulphate, gr. 4.33; calcium carbonate, gr. 3.26; magnesium carbonate, gr. 2.85; iron oxide and alumina, gr. 0.15. Total, 18.89 grains. The water is free from nitrates and nitrites or other organic impurities, and will keep indefinitely without undergoing impairment of mineral properties. The water is bottled and shipped to all points. It will be found use'ful in the diseases benefited by this class of waters. Elaborate bathing facilities are supplied to visi- tors at the springs. James K. Crook. SAFFRON.— Spanish Saffron. Crocus U. S. P., B. P., P. G. Stigmata croci. Saffran, Fr. Cod. The dried stigmas of Crocus satiims L. (fam. Iridacem). The saffron plant is a perennial herb, resembling col- chicum, but wi|h an inferior ovary. It grows from a flattened fleshy corm and bears one or two flowers, each possessing a long thread-shaped style, terminating in three long stigmatic branches. These branches, with a very short portion of the style, •are collected and dried and con- stitute the drug. The nativity of the plant is not certainly known. Cultivated plants yield the whole of the product, which is mostly exported from southern Europe, especially Spain. It grows read- ily in most warm-temperate re- gions, but the profitable produc- Fig. 4139.— Spanish Saffron, tion of saffron is chiefly a labor problem, since nearly four thou- sand flowers are required to yield an ounce, and its suc- cessful production requires exceedingly low-priced labor. Description. — Separate stigmas or three attached to a very short portion of their style, each 2 to 3 cm. (about 1 in.) long, flattish-filiform below, dilated and funnel- form tubular above, with the margin irregularly notched ; orange-brown, the style portion yellow; texture some- what cartilaginous, unctuous to the touch, strongly and peculiarly aromatic and bitterish. When chewed it tinges the saliva deep orange-yellow. So costly a drug is of course subject to numerous and cunningly devised methods of adulteration, some of which are provided against as follows by our Pharma- copoeia : "When soaked in water, it should not deposit any pul- verulent, mineral matter, nor show the presence of or- ganic substances differing in shape from that described. On agitating 1 part of saffron with 100,000 parts of water, the liquid will acquire a distinct yellow color. No color is imparted to benzin agitated with saffron (ab- sence of picric acid and some other coal-tar colors). On drying saffron at 100° C. (212° F.), it should not lose more than rourteen per cent, of its weight (absence of added water). When thus dried, and ignited with free access of air, 100 parts of the dry saffron should not leave more than 7. 5 per cent, of ash (absence of foreign inorganic substances). One of the commonest methods of increasing the yield of saffron is that of collecting a large portion of the style with the stigmas, and the possible presence of these styles is referred to in our own and other pharmacopoeias. Onion roots have been chopped up and colored to sub- stitute saffron, as have other fibrous or filamentous bodies. The most important substitute, however, and that very generally sold for saffron in this country, is safllower, which will be found described at the close of this article. The detection of adulterants of nearly all kinds is far less easy when the product is pressed into cakes, so that loose or " hay " saffron is always to be pre- ferred. All things considered, the microscope probably offers the most reliable means for detecting adulterants, and a moderately low power suffices for most of them. Constituents. — Saffron owes its odor to about one per cent, of a volatile oil, which differs considerably ac- cording to the method of distillation, being sometimes lighter, sometimes heavier than water. Its color is due to the presence of the yellow glucoside crocin (CmHtoOis). which yields reddish crocetin. The name polychroit was formerly applied to this coloring matter, but the sub- stance so described was subsequently found to be a mixture, consisting largely of crocin. The bitterish taste of crocus is due to a glucoside which has been called picrocrocin. The other constituents of crocus are unim- portant. Crocin is very slightly soluble in water, unless rendered alkaline, but is soluble in alcohol. It becomes blue, then violet-brown with concentrated sulphuric acid, and green, afterward yellow and brown, with nitric acid. The yield of volatile oil is greatly increased by previous treatment with sulphuric acid. Action and Use. — Crocus has had a wonderful his- tory as a drug. It was credited with remarkable powers by the ancients, and is still so, to some extent, by the more ignorant classes. It, however, probably possesses no other medicinal properties than those of a mild aro- matic, stimulant, carminative, and antispasmodic, and may be given in doses of 0.3-2 gm. (gr. v.-xxx.). The Pharmacopoeia provides a ten-per-cent. tincture. As used at the present day, especially in the United States, it is almost wholly for the purposes of coloring and slight flavoring. Saffloioer, Carthamus, African w dyer^s saffron, False, American or Thistle saffron, consists of the florets of Car- thamus tinctorius L. (fam. Composite). Although called American saffron, this plant is of Oriental nativity. It is widely cultivated for ornament and also, to some extent, for the product here described. It produces handsome large flower heads, of an orange-yellow color, at the ends of the branches. From these the florets are plucked out, dried, and constitute the drug. They were formerly largely used for dyeing purposes and are still so used to a considerable extent in India. They constitute a red or deep orange-red mass, of a rather slight characteristic odor and an aromatic and bitterish taste. The individual florets are about 2 cm. Q in.) long, though often broken, tubular, and very deeply divided into five linear and nearly equal lobes. The stamens have long exserted co- herent anthers and a slender style which is considerably longer than the stamens. The ovary should not be pres- ent. The principal coloring matter of safllower is deep yellow and constitutes one-fourth or more of the weight of the drug. It is known as safflor-yellow (C 2 4H 3 oOi 6 ) and is soluble in water. There is also a fraction of one per cent, of the red coloring matter carthamic acid or carthamin (C 14 Hi„0,), which is not soluble in water but gives a beautiful purple color in alcohol. The latter coloring matter exists in commerce as a reddish-brown, somewhat metallic powder. It is used in rouge-making. The properties and uses of safllower differ but little from those of saffron, and its principal use is in fact the sub- stitution of the latter. Henry H. Busby. SUGE.— Garden Sage. Salvia, U. S. P. The dried leaves of Salvia officinalis L. (fam. Labiatce). This is a half shrubby, gray-hairy perennial, the stems dying down to within a foot or so of the ground in the fall, but branching very freely into herbaceous flowering branches, which are quadrangular and attain a height of two or three feet. The leaves are opposite, the flowers in a mixed spike, with two-lipped, pubescent, bell- shaped calyx, and a conspicuously labiate, blue corolla, with a ring of hairs at the base, inside ; upper lip of the corolla concave, notched at the apex, the lower three- lobed; the central one much the largest and longest. Perfect stamens two, with widely divergent anther cells, but one of which in each stamen is perfect. Ovary four- lobed. Fruit of four nutlets. Sage, like so many others of our household mints, is a native of Southern Europe. It has, however, been cultivated for centuries, and trans- planted to all temperate countries. Leaves rather long and stoutly petioled, the blades 3-7 cm. (about 1-3 in.) long and nearly half as broad, oblong or slightly broader Saint Augustine. Saint Louis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. below the middle, rounded or subcordate at the base, mostly blunt at the summit, crenulate, thickish, gray- green, and densely hairy, especially underneath, very strongly veined, the veins finely reticulate, often pinkish or purplish, as is the petiole ; aromatic in odor and taste, the latter also bitter and somewhat astringent. Sage owes its very characteristic odor and its proper- ties as an aromatic drug to a peculiar volatile oil (less than one per cent, in the fresh, up to 2.5 per cent, of the dried leaves). It also contains an unknown bitter sub- stance and apparently tannin, together with resin and a little gum. Oil of sage is a commercial article, and is of a yellowish or greenish-yellow color, with a specific gravity of about 0.92. Its chief constituent has been called salviol, but it is now considered identical with thu- jone, the active constituent of Arbor vitre, and this occurs also in some other volatile oils. A small amount of cineol is also contained. Sage resembles the rest of the Mint family in its gen- eral action ; it is aromatic, a gastric stimulant, and by reason of its bitterness also tonic. It is also, what all are not, mildly astringent. In large quantities of hot water, like many other mints, it is given as a sudorific in the beginning of feverish colds, etc. Sage is useful in mouth washes and as a gargle. It is, however, almost entirely a domestic remedy, and even as such but little used of late, although formerly in high repute. It is one of the ingredients of the formerly official aromatic wine ( Vinum Aromaticum), an old-fashioned liniment. W. P. Bolles. SAINT AUGUSTINE, FLORIDA.— This picturesque and well-known winter resort is situated on the Atlantic coast of Florida, thirty-eight miles southeast from Jack- sonville, and about two hundred and fifty miles north of Palm Beach. The city occupies a narrow peninsula opposite Anastasia Island, which forms a breakwater against the open ocean. The surrounding country is flat and sandy and covered with the scrub palmetto. The town is the oldest in the United States, and has a permanent population of between four and five thou- sand inhabitants, which number is doubled or more at the height of the season. The city retains many of its antiquities, and is exceedingly quaint and attractive. The narrow streets; the ancient Spanish "coquina," or shell-limestone residences, with their overhanging balconies; the old ''City Hall," and Fort Marion, are all exceedingly interesting relics of the Spanisli occupancy. Many new and attractive buildings have of late years sprung up — several extensive hotels of the Spanish style of architecture, with beautiful grounds and courtyards ; villas, with grounds ornamented with orange, lemon, and fig trees, palms, and a variety of tropical flowers and shrubs ; churches, convents, and the restored Cathedral and Old Market. The attractions at this resort are many and varied, as can easily be imagined. Besides those already mentioned, there are a United States military post, with daily guard mount, the sea wall affording a delightful promenade along the water front; many excursions by water; visits to the orange groves; drives, hunting, fishing, sailing, golf, and the never-ending delight of wandering through the old town. Connected with one of the hotels is a casino, where are Turkish baths, a swimming pool, va- rious entertainment halls, lawn-tennis conrtsretc. The winter climate is a mild, equable, moist one ; and in summer the heat is tempered by the sea breezes. Frosts are rare. Although the climate is of a somewhat less tropical nature than that of the resorts on the lower half of the peninsula, such as Palm Beach, Tampa, and Miami, still a very comfortable, mild atmosphere is found here in the winter, and there is a good proportion of sunny days. The average mean temperature of twenty years for the four seasons, as given by Dr. Wall (T/ie Climatologist, October 15th, 1891), is as follows (degrees Fahr.): Spring, 68.5°; summer, 80.3°; autumn, 71.5°; winter, 58.1°; and for the whole year, 69.6°. For the four winter months, according to the same authority, it is, for December, 57.2° ; January, 57= ; February, 59.9° ; March, 63.3°. The average yearly rainfall is about 49 inches, varying quite considerably in different years; for example, it was 67.4 inches in 1880 and 33.9 inches in 1851. The least rainfall appears to be in Jan uary. The prevailing winds are from the northeast. The climatic data of Jacksonville, which is only thirty miles to the north of St. Augustine, can be taken as fairly accurately representing those of the latter resort, and the reader is referred to the article upon Jacksonville in Vol. V. of the Handbook for more ex tended meteorological facts. The water supply is abundant and obtained from arte- sian wells ; and the streets are clean and well lighted. The sanitary conditions of the hotels are carefully looked after. There is a well-appointed, indeed a luxurious, hydro- therapeutic establishment where hot and cold saline and hydro-electric baths are given by skilled attendants ; and cases of rheumatism, gout, and nervous disorders are treated in this way. The Nauheim baths and the Schott system of treatment for heart disease ; various methods of electrical applications, gymnastics, douches, and mas- sage are also included in this establishment. January, February, and March are the months in which St. Augustine is the most frequented. On ac- count of its easy accessibility, mild climate, excellent accommodations and many attractions, this has become a popular and fashionable winter resort, and has been compared to Newport and Saratoga. Excursions to other portions of Florida can easily be made from this point. Edward 0. Otis. SAINT CATHARINE'S WELL.— Post-Office.— St. Catharine's, Ontario. Hotel, The Wetland House. Access. — Via" Grand Trunk Railway from Toronto, or Buffalo. Analysis (Professor Croft). — Ten thousand grains of water contain: Carbonate of iron, gr. 0.5210; carbonate of lime, gr. 0.0820; sulphate of lime, gr. 19.7934; chlor- ide of calcium, gr. 174.4876 ; chloride of magnesium, gr. 40.6644; chloride of sodium, gr. 378.4196; chloride of potassium, gr. 2.8119 ; bromide oi sodium, a trace; iodide of sodium, gr. 0.0140. Total, 616.7938 grains. St. Catharine's is situated twelve miles from Niagara Falls in what is termed " the Garden of Canada. " There are a number of springs which have long been famous, and at different times sanatoria have been opened. The Welland is under excellent management and has during the past year been enlarged and furnished with all the appliances of a modern sanatorium. A resident physician is in charge with a staff of skilled nurses. Every provi- sion is made to utilize the water after the most approved methods of hydrotherapeutics. The hotel is open throughout the year. Beaumont Small. SAINT CLAIR SPRINGS.— St. Clair County, Michigan. Post-Office. — St. Clair Springs. Hotel, The Oak- land. Access.— From Detroit by steamer from the foot of Griswold Street, twice daily ; distance fifty miles. Also from Detroit via Grand Trunk Railway (foot of Brush Street), twice daily; distance fifty -one miles. Railroad connection for springs can also be made at St. Thomas, Ontario, via Canada Southern Railroad. Steamer con- nection once daily is made at Port Huron, Mich. St. Clair Springs is one of the strictly first-class health and pleasure resorts of the United States. The Oakland Hotel, situated in a tract of about one hundred and sixty- five acres fronting on the St. Clair River, at the extreme southern portion of the city of St. Clair, affords all the comforts, conveniences, and luxuries to be found at our older Eastern resorts or at the European spas. The hotel is open for the reception of health- or pleasure-seekers all the year round. Two classes of mineral waters of very pronounced yet very different type are found here. The first of these is a powerful muriated saline water The analysis is by Professor Duffleld : One United States gallon contains (solids): Sodium REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Saint Augustine. Saint Louis. chloride, gr. 8,120; calcium chloride, gr. 7,382.20; magnesium chloride, gr. 1,012.20; calcium sulphate, gr. 144.20; silica, gr. 416; alumina, gr. 830; and traces of magnesium carbonate, calcium carbonate, magnesium iodide, and magnesium bromide. Total, 17,904.60 grains. Sulphureted hydrogen gas, 25.59 cubic inches. It 'will be observed that the water contains an unusu- ally large quantity of chloride of lime. The salt is be- lieved by some observers to possess valuable alterative properties and to be 6f great assistance in the treatment of the strumous diathesis. The water also possesses all the well-known virtues of the densely charged chloride- of-sodium groups. It is used only for bathing purposes and as a spray or douche. An elegant and elaborate bathhouse, presenting all varieties of baths, sprays, douches, etc., is maintained in connection with the hotel. The " Salutaris " is a natural gaseous alkaline mineral water, very wholesome and pure. It is said to be en- tirely free from organic matter, and constitutes an excel- lent table water. It is bottled and extensively sold in the United States. The attractions in and about the Oakland Hotel are of a manifold character: expansive shaded lawns, pictur- esque drives; boating and sailing on the river, and all the indoor pastimes of the day will be found here. James Ii. Crook. SAINT HELENA WHITE SULPHUR SPRINGS.— Napa County, California. Post-Office. — St. Helena. Hotel and cottages. Access. — Take ferry from San Francisco foot of Mar- ket Street, at 8 a.m. and 4 p.m. Arrive at St. Helena vi6 Calistoga train at 11:03 a.m. and 7:08 p.m. Take stage to springs, two miles distant. One United States Gallon Contains: Solids. Spring No. 2. Grains. Spring No. 6. Grains. Spring No. 7. Grains. Carbonate of iron Carbonate of magnesium. Chloride of calcium Sulphides of sodium and .62 8.26 21.72 1.32 .87 2.65 .56 11.33 23.41 .86 2.22 1.85 4.36 12.84 14.23 .78 .65 1.62 35.44 40.23 34.48 Gases. Cubic inches. Cubic inches. Sulphureted hydrogen — 6.15 4.25 Trace. This beautiful summer resort is located in one of Cali- fornia's loveliest, valleys. The neighboring mountain- sides are covered with forests, shrubbery, ferns, and wild flowers of every description. Brooks and cascades are seen on every hand. The grand old California redwoods, which are found here in great abundance, are alone worth a visit to this region. The mineral springs are numerous and valuable, and chiefly of the saline-chalybeate type. Mr. Sanford Johnson, the proprietor, furnishes us with the accompanying analysis of three of the springs. There are six other springs which have not been com- pletely analyzed. The waters vary in temperature from 64.4° to 97.25° F. The analysis shows them to possess valuable tonic properties. They are said to have con- siderable value in rheumatism and kidney affections. James K. Orook. SAINT LOUIS, MO.— This great city of nearly 600,000 inhabitants is situated in the northeastern corner of Mis- souri upon the Mississippi River, not far from its junc- tion with the Missouri. A description of the city is hardly necessary or perti- nent in this connection, as the climate is the chief consideration, of which certain marked peculiarities deserve mention. In the first place, as will be observed from the table, the excessive extremes of temperature are striking, the annual range being 123.4° F. Although the winter mean temperature is only a few degrees higher than that of New York, for example, the mean summer temperature is five and one-third degrees higher. In July a maxi- mum temperature of 104° F. is noted, while in January a minimum temperature of — 16° F. occurred in the cold wave of 1889. St. Louis is called a " Southern city, " and yet it is seen that the winters are severe and quite like those of a Northern city. The summers are usually very "hot, the nights as well as the days, and a continuous high temperature may exist for many days in succession; moreover, this heat may continue through the month of September. In July, 1901, there was hardly a day for three weeks in which the temperature was not 100° F. or over. The daily range of temperature is also seen to be considerable, and, consequently, one might hastily con- clude that the summer nights would be comparatively cool ; but if the day temperature is very high, a diminu- tion of fifteen or eighteen degrees would still give a high night temperature. Another striking feature of this climate is the preva- lence of south winds throughout the year, except in March, when the blizzards change the direction from south to northwest. The mean relative humidity indicates a moderate amount of moisture, a little less than that of New York City. The rainfall is not excessive and is pretty evenly distributed throughout the year, rather more falling in the spring and summer. There are a few more clear and fair days in St. Louis than in New York, especially in the summer and autumn. The flatness of the surround- ing country and the atmospheric conditions favor the Climate of St. Louis, Latitude, 38° 38' ; Longitude, 90° 12'. Period of Observation, Thirteen Years. a 4 a S >-3 02 S (a • 1 > be p 'C a 02 a a s 02 a a a 31.7° 43.1° 66.1° 78.8° 68.0° 42.4° 54.7° 76.8° 55.9° 34.0° 15.8 16.8 18.7 18.2 19.2 15.5 38.7 53.5 75.4 88.2 79.2 52.1 22.9 36.7 56.7 70.0 60.0 36.6 72.0 82.0 93.0 104.0 101.5 82.0 -16.0 8.0 32.0 57.0 40.0 5.0 71.2* 66* 64.2* 67.9* 64.7* 67.9* 63.3* 67.4* 65.8* 70.9* 2.19 3.04 3.86 4.36 2.55 2.79 10.25 11.74 8.12 7.48 S. N. w. S. S. S. S. S. S. S. S. 10.2 11.6 9.7 7.7 8.5 10.6 10.7 8.0 9.5 10.2 8.8 7.7 9.8 11.4 13.9 7.7 26.9 33.5 34.4 24.5 11.3 11.9 11.5 12.9 10.9 12.2 35.2 40.5 34.9 33.0 20.1 19.6 21.3 24.3 24.8 19.9 62.1 74.0 69.3 57.5 Temperature, Degrees Fahr.— Average or normal Average daily range Mean of warmest Mean of coldest Highest or maximum Lowest or minimum Humidity- Average mean relative Precipitation- Average in inches Wind- Prevailing direction Average hourly velocity in miles Weather— .Average number of clear days Average number of fair days Average number of clear and fair days 55.3° 60.8* 37.59 9.6 119.3 143.6 262.9 Saint Louis Spring. Salicylic Acid. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. formation of tornadoes; and on May 27th, 1896, there oc- curred in St. Louis one of the most terrific ones ever known in the United States, ploughing in a moment a huge furrow through the city and destroying a large number of lives and an immense amount of property. Such calamities, however, are rare, but, nevertheless, the latent conditions are always existent, and what has happened may happen again. During the surmner months all who are able seek a cooler climate at the seashore or in the mountains ; but during the rest of the year St. Louis is a comfortable and wholesome place of residence. It has been feared that the Chicago drainage canal, which empties into the Illinois River, — which latter in turn flows into the Missis- sippi above St. Louis, — might pollute the waters of this river as it flows past St. Louis. No sure evidence, however, to the writer's knowledge, has been adduced to show that this is the fact, or that the drinking-water, which is derived from the river, is injuriously affected. For a description of the manifold attractions in and about the city, the guide books must be consulted ; and for the history of the founding of the city, the reader is referred to Parkman's fascinating works. From St. Louis interesting excursions can be made either up the river to St. Paul, or in the other direction to New Orleans. The steamers are comfortable and com- modious. From St. Louis to New Orleans is a distance of 1,250 miles, and the steamer occupies about a week in traversing it. For one who desires a slow, restful journey amidst oddly picturesque scenery, a journey soothing to tired nerves and yet of strange interest, this voyage down the Mississippi can be unqualifiedly recom- mended from personal experience. Edward 0. Otis. SAINT LOUIS SPRING.— Gratiot County, Michigan. Post-Office. — St. Louis. Hotels and sanatoriums. Analysis by S. P. Duffield: One United States gallon contains (solids): Sodium bicarbonate, gr. 88.66; calcium bicarbonate, gr. 57.83; magnesium bicarbonate, gr. 14.58 ; iron bicarbonate, gr. 1 ; calcium sulphate, gr. 55.41; calcium silicate, gr. 5.60; silica, gr. 2.40; organic matter and loss, gr. 1.66. Total, 227.14 grains. Gases, sulphureted hydrogen, a trace; carbonic acid, 5.17 cubic inches. The results of treatment with these waters, according to Dr. Stiles Kennedy, show them to be especially bene- ficial in dyspepsia, neuralgia, and chronic rheumatism. The water, as shown by the analysis, is strongly alkaline, and also contains sufficient iron to impart to it the prop- erties of the chalybeate class. The waters were once supposed to be strongly magnetic, but it has been proved by the experiments of "Walton, and corroborated by a committee of the Michigan State Medical Society, that the so-called magnetic properties were derived from the metallic tubing which encased the well. The resort is still kept up well and is very popular. James K. Crook. SAINT MORITZ, SWITZERLAND. • See Engadine. SAINT PAUL, MINN.— This city, and several other points in Minnesota, wer- formerly popular as winter health resorts for consumptives, on the theory that steady cold weather was peculiarly bracing to the constitution, and thus hardened the patient was put in a more favor- able condition to overcome his disease. There is un- doubted truth in this, provided the air is pure as well as cold, and provided other favorable climatic factors exist, such as sunshine, absence of high winds, and dryness. There have been developed, however, other and better climates of the bracing winter type, such as the various well-known resorts in the Alps and in Colorado ; and, in consequence, the former reputation of Minnesota has declined. Further, large cities are obviously never so favorable as health resorts for pulmonary tuberculosis, and hence St. Paul and its sister city, Minneapolis, now grown so large, could not be recommended for a resi- dence to those suffering from this disease, even if the climate were better than it actually is. The characteristics of this climate are, first of all, the steady cold winter weather, the mean temperature of the four months, December, January. February, and March, being 19.6° F., while the minimum temperature has been as low as — 39° F. in December and — 31° in January. Secondly, may be mentioned the freedom from the sud- den and constant great variations in temperature so com- mon along the Atlantic coast ; it is very cold in winter, but it is a steady cold, and there are no thaws. Again, when we consider the low winter temperature, a relative humidity of 72.4 per cent, indicates a dry atmosphere, quite different from that of New York City, for instance, with about the same relative humidity in winter, but with an average mean winter temperature 14.8° F. higher, the absolute humidity at St. Paul being only half as great in the winter as at New York City ; so that we have a dry as well as a cold atmosphere. The average precipitation is seen to be small, about two-thirds of that of New York City. There is no great amount o£ wind at St. Paul, particu- larly in the winter ; and a very considerable amount of sunshine. In both of these respects St. Paul shows a marked superiority over New York City. From its inland location, St. Paul is free from all those perturbations of temperature caused by the influence of the sea, which prevail in the large sea-bound cities of the United States, or in the cities lying upon the great lakes. St. Paul is a beautiful city, and affords many attrac- tive excursions in the vicinity ; — one is to Lake Minne- tonka, forty miles distant, a popular summer resort with hotels and cottages, where the air is pure and invigorat- ing, and where many opportunities are afforded for out- of-door life. Convalescents and those suffering from ner- vous affections are said to do well in this climate. From St. Paul the journey down the Mississippi River begins, Climate of St. Paul, Minn. Latitude, 44° 58' ; Longitude, 93° 3'. Years. Period op Observation, Thirteen January. March. May. July. Sep- tember. No- vember. 12.9° 28.5° 58.8° 71.8° 58.4° 30.1° 24.3 41.2 68.7 82.8 70.7 40.2 5.8 22.2 48.3 62.7 50.7 28.8 19.5 19.0 20.4 20.1 20.0 16.4 49.0 C8.ll 94.0 100.0 94.0 72.0 -31.0 -22.5 24.0 46.0 30.0 -24.5 72.1* 69* 60.5* 69. 9* 70.7* 72* 1.07 1.64 3.72 3.22 3.26 1.42 N. W. N. W. S. E. S. E. S. E. N. W. 7.8 9.2 9.6 7.2 8.2 8.3 8 8.3 8.8 10.6 9.1 6.5 13 12.0 14.2 15.8 13.8 13.7 21 20.3 23.0 26.4 22.9 20.2 Tear. Temperature, Degrees Fahr.— Average or normal Mean of warmest Mean of coldest Average daily range Highest or maximum Lowest or minimum Humidity- Average mean relative Precipitation— Average in inches Wind- Prevailing direction Average hourly velocity in miles Weather- Average number of clear days Average number of fair days Average number of clear and fair days 8.8 12.8 21.6 43.7° 69.1* 29.94 S. E. 8.4 106.2 . 159.9 266.1 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Saint 1,011 Im Spring. Salicylic Acid. and the portion between this city and St. Louis, consti- tuting the first stage, is one of beautiful and grand scen- ery. The distance is about eight hundred miles. Edwa/rd 0. Otis. SALACETOL — salantol, CeH^OH.CO.OCHa.COCHs — is a compound of acetone and salicylic acid containing seventy-one per cent, of the latter. It occurs as fine acic- ular crystals or scales insoluble in cold water, slightly soluble in cold alcohol, and freely soluble in hot alcohol, ether, and chloroform. In its action it resembles salol, the analogous compound of phenol and salicylic acid, and like it separates into its components in the intes- tine. The dose is 1-3 gm. (gr. xv.-xlv.). W. A. Bastedo. SALACTOL is a solution of the lactate and salicylate of sodium in a one-per-cent. solution of hydrogen diox- ide. It is employed in diphtheria as a gargle, or applied to the throat with a brush. W. A. Bastedo. SM.\Cm.—(Salicinum, U. S. P., B. P.), C, a H 1B 0, = 285.33. This is a neutral principle obtained from several species of Salix and Populus (Pam. Salicacece). Salicin is easily prepared from willow bark by extract- ing with water, precipitating tannin, etc., with litharge, ■ evaporating and crystallizing out the salicin, and purify- ing by re-solution and repetition of the process. Prom populin it is prepared by boiling with lime water or barium hydroxide. It can also be prepared synthetically. The following is the official description : Colorless, or white, silky, shining crystalline needles, or a crystalline powder, odorless, and having a very bit- ter taste. Permanent in the air. Soluble, at 15° C. (59° P.), in 28 parts of water, and in 30 parts of alcohol; in 0.7 part of boiling water, and in 2 parts of boiling alcohol ; almost insoluble in ether or chloroform. When heated to 198° C. (388.4° F.), salicin melts, yielding a colorless liquid which, on cooling, congeals to a crystalline mass. Upon ignition, it is consumed, leav- ing no residue. Salicin is neutral to litmus paper. On heating a small portion of salicin in a test tube until it turns brown, then adding a few cubic centime- tres of water, and afterward a drop of ferric chloride T.S., a violet color will be produced. Cold, concentrated sulphuric acid dissolves salicin with a red color ; the solution, after the addition of water, be- comes colorless, and deposits a dark-red powder insoluble in water or alcohol. On heating a small portion of salicin with 1 c.c. of potassium dichromate T.S. and 2 c.c. of sulphuric acid, the odor of salicylic aldehyde (or of oil of meadow-sweet, Spirasa ulmwria L., Pam. Bosacece) will become notice- able. The aqueous solution of salicin is not precipitated by tannic or picric acid, nor by mercuric potassium iodide T.S. (absence of, and difference from, alkaloids). Salicin is a glucoside, yielding, upon treatment with dilute acids or a powerful galvanic current, glucose and saliretin, or saligenin. It is readily convertible into sali- cylic and related acids and numerous other compounds. In the svstem it is partly converted into salicylic acid, so that its effects are very similar to those of that sub- stance ; but, since the percentage thus changed appears inconstant, its action is very irregular. Between two and three ounces of it are recorded as having been taken with no marked effect, though far smaller amounts are often very active. Although its chemical reactions out- side of the body are thus of great interest, they lend but little assistance in determining its physiological action, and its therapeutics is almost wholly empirical. As in- dicated above, its action is, weakly and irregularly, that of salicylic acid. Salicin has undoubted antipyretic power, although less than is possessed by quinine or salicylic acid ; its anti- periodic action is much less than that of either of them. As a remedy in rheumatism, salicin has also been obliged to yield to the more useful salicylic acid. As a tonic, in small doses, it is occasionally used, but is far inferior to gentian or quinine. Four or five grams ( 3 i. ad 3 iss.) may be given as a dose, and repeated every three hours; as a tonic 1 or 2 dcgm. (gr. iss. ad gr. iij.) is sufficient. Henry H. Busby. SALICYLAMIDE. — A compound prepared from sali- cylic acid by.the introduction of the amidogen radical. Its chemical formula is C»H 4 ,OH,CONH-.. The benefit of the combined action of this stimulating radical had already been demonstrated in chloralamide, and the same advantage was looked for in salicylamide. It may be prepared by the action of concentrated ammonia upon oil of wintergreen. It forms in colorless crystals and in thin transparent plates, melting at 142° C. It is soluble in alcohol, ether, chloroform, readily soluble in hot water, and in two hundred and fifty parts of cold water. Salicylamide was proposed as a substitute for salicylic acid and its salts, the advantage claimed for it being its greater solubility, its tastelessness, and its freedom from any depressing action on the system. A very careful study of its physiological properties has been made by Dr. W. B. Nesbitt, of Toronto (Therapeutic Gazette, Oc- tober, 1891). He sums up the result as follows: 1. Pharmacologically, it prevents conduction in nerve ; par- alyzes nerve first, then muscle. 2. On the heart, its chief effect is on the motor apparatus, most probably through its activity on conduction. 3. Diminishes spinal reflex for motor impulses. 4. Diminishes spinal con- ductivity for painful impressions. 5. Diminishes mus- cular irritability. 6. In mammals, it exerts no particular effect on respiration. 7. It produces no particular effect on blood pressure. In medicinal doses it reduces tem- perature and causes ataxic gait and hebetude in fowls. It is employed for all conditions in which the salicy- lates are indicated. The dose advised is about fifteen grains daily, in divided doses of three to five grains. Beaumont Small. SALICYL-BROMANILID. See Antinervine. SALICYLIC ACID AND SALICYLATES.— Salicylic acid, chemically ortho-oxybenzoic acid, HCtHsOs, takes its name from the principle salicin, found in willow bark, from which substance it is possible to make salicylic acid by fusion with potassium hydrate. Salicylic acid in the condition of the ethereal salt, methyl salicylate, constitutes about ninety per cent, of oil of gaultheria (wintergreen), and occurs also in other plants. Salicylic acid can be made from oil of gaultheria, but at present almost all the acid used in medicine is made, by the proc- ess of Kolbe, from carbolic acid. The principle of this process consists in the forcing of a molecule of carbon dioxide upon the molecule of carbolic acid, an addition which just converts one molecule of the phenol into one of salicylic acid. In this process, carbolic acid and a concentrated solution of soda are first evaporated to dry- ness, and over the product, heated, a stream of dry car- bon dioxide is made to pass. As a result, one-half of the phenol used is converted into salicylic acid in the condi- tion of sodium salicylate, which salt, on decomposition by treatment of its aqueous solution with hydrochloric acid, yields salicylic acid under its own form. Kolbe's proc- ess, by reason of its cheapness, has practically super- seded all others for the procurement of salicylic acid. It will thus be seen that both the natural and the artifi- cial acids are prone to impurities. Their purification, especially that of the synthetic, is a matter of much im- portance. Carbolic acid is the commonest and one of the most serious impurities, as are the creosotic acids (see be- low) frequently occurring in the artificial variety. Sali- cylic acid is official in the United States Pharmacopoeia under the title Acidum Salicylicum, Salicylic Acid. It occurs in fine, light, perfectly white needle-shaped crys- tals, or in a white crystalline powder. A reddish tinge in a sample of the acid signifies impurity, and such a sample SaKsulplfonic Ac ,a.I™RENCE HANDBOOK OF THE MEDICAL SCIENCES. should be rejected. Salicylic acid is permanent in the air ; is, when pure, free from odor of carbolic acid, but has a sweetish taste, with an acrid after-flavor. It dissolves in 450 parts of cold water and in 14 parts of boiling water ; in 2.4 parts of cold alcohol, and very readily in boiling alcohol. Although salicylic acid is but feebly soluble in cold water, it dissolves freely in many saliDe solutions. Thus the pharmacopceial solution of ammonium acetate will dissolve twenty -five per cent, of salicylic acid; a twelve-and-a-half-per-cent. aqueous solution of potas- sium acetate will dissolve twelve and a half per cent, of the acid ; a twelve-and-a-half -per cent, solution of potas- sium citrate in equal volumes of glycerin and water will dissolve six per cent. All of these solutions possess the sharp stinging taste of the uncombined acid. A service- able and permanent solution of the acid, and one that in- stead of being sharp to the taste has a pure bitter flavor only, can be made as follows: Dissolve two parts of borax in twelve of glycerin by the aid of heat ; add one part of salicylic acid, continue the heat, and stir until the acid dissolves. Almost all solutions of salicylic acid, either immediately or after a while, turn of a reddish or of a smoky color, resembling that of solutions of carbolic acid. Salicylic acid is incompatible with strong oxidizing agents, like potassium permanganate, and with chlorine, bromine, iodine, ferric salts, carbonates, the most of which it decomposes, and spirit of nitrous ether. A soft or semi-liquid mass is formed with exalgin, antipyrin, phenacetin, urethane, and other synthetics, as well as with lead acetate and sodium phosphate. The salicylates give precipitates with strong solutions of most alkaloidal salts, as well as with strong acids. Lime water also yields a precipitate. Salicylic acid, taken into the mouth, has not much taste, proper, but speedily and quite suddenly after the tasting a sharp stinging seizes the throat, often severe enough to bring tears to the eyes. Similarly, a little of the dry acid snuffed up the nostrils will sting quite strongly. The acid brings sharp pain to cuts and abra- sions, but, swallowed, is much less irritant to the stomach than its effects on the throat would lead to suppose. Large doses, so taken, may upset digestion and cause a strong sensation of heat, and even actual burning pain, but no serious or lasting results follow. The acid is rapidly absorbed from the stomach into the circulation, presumably in saline combination, and thereupon exerts the peculiar influence characteristic of the salicylates (see Salicylates, below). Salicylic acid was at first used as an internal medicine for the procurement of the therapeutic effects of the sali- cylates; but now, and very properly, salicylates them- selves, because of their freedom from the locally irritant action of the uncombined acid, have superseded the acid for this purpose. The present medicinal application of the acid is for local purposes as a deodorant, detergent, or so-called antiseptic — purposes which salicylic acid fulfils by reason of its having a fairly potent germ-steri- lizing faculty. (See Salicylic Acid in article Germicides.) For general local use, the solution of the acid in a glyc- erin solution of borax is convenient, this solution bearing any necessary dilution with either water or alcohol with- out precipitation. A dilution representing a two-per- cent, solution of acid is one very commonly employed. For other salicylic preparations for local use, see Salicylic Acid in article Antiseptics. Salicylates. —In saline combination, whether with metallic or ethereal bases, the local pungency of free salicylic acid disappears while yet the faculty for consti- tutional action remains. As already said, it is probable that the acid, when taken as an internal medicine, enters the circulation only after conversion into a salicylate, so that, as a matter of fact, what is commonly called the constitutional action of salicylic acid is, so far as we know, the action of a salicylate. The constitutional effects in question are as follows: After a full dose a non- pyrexial subject experiences, in about fifteen minutes, a moderate reddening of the face with a sense of fulness of the head, or perhaps even a pronounced headache, and a buzzing or roaring in the ears precisely similar to what occurs in cinchonism. Almost simultaneously free per- spiration begins, and, according to dose, there is more or less tendency to a reduction of pulse rate, of respiration rate, and of body temperature. Tests for salicylic acid will reveal the presence of the substance in the urine, the saliva, and the sweat. The urine, furthermore, will be discolored, appearing brown by reflected and green by transmitted light, from the presence of indican or of py- rocatechin. It will also contain a something that will re- duce copper salts in copper test solutions (Brunton), and will show an increased amount of urea and uric acid. In overdoses, salicylates readily irritate the kidneys, setting up albuminuria; may derange the cerebral faculties, causing hallucinations and delirium; and may danger- ously or even fatally depress the functions of heart and lungs, determining collapse or death by failure of respi- ration. These several untoward effects occur very irreg- ularly, and, according to Squibb, in "a very large_ pro- portion " of instances are determined, not by the salicylic acid, hut by a contaminating acid very commonly present in market samples of salicylic acid, and hence in salicy- lates derived therefrom. The constitutional effects of salicylates, which are valuable in medicine, do not ap- pear in experimentation with a subject in health. They consist, in general, in a reduction of fever temperatures, and, in particular, in an abatement of pains in fibrous tissues, notably the pains in acute articular rheumatism. The antipyretic power of salicylates is second to none, in all the three elements of quickness, degree, and duration of reduction of temperature. For a full antipyretic effect, however, considerable dosage is necessary — con- siderable enough to cause disagreeable sweating, tinnitus aurium, depression of pulse and respiration rate, and, every now and then, actual toxic symptoms. Other anti- pyretics, therefore, which act more kindly, are prefer- able, except in rheumatism. The antirheumatic faculty of salicylates is unapproached by any other known medi- cine, so that, as is well known, salicylates constitute a standard set of medicines for the treatment of acute rheu- matism. Under salicylate medication the fever lessens, pains abate, and the disease runs a shorter as well as milder course. It is therefore particularly as remedies for rheumatism and, though not so surely, for gout that salicylates are prized in medicine. The salicylates in common medical use for the purpose of salicylate medication are the salicylates, respectively, of sodium, lithium, and methyl. The salicylates, respect- ively, of physostigmine, quinine, and other alkaloids, are used for the sake of the medicinal action of the respective bases only. Sodium Salicylate, 2NaC 7 H 5 O a .H 2 0. The salt is official in the United States Pharmacopoeia under the title Sodii Salicylas, Sodium Salicylate. It occurs as an amorphous powder, white, without odor, and having a sweetish, saline, and slightly alkaline taste. It is permanent in the air, dissolves readily in water, glycerin, and boiling alcohol. In cold alcohol it requires six parts for solu- tion. It should be kept in well-stoppered bottles, pro- tected from heat and light. Sodium salicylate is the most commonly used salicylate, and is a very important medicine. It is easily made in solution by mixing sali- cylic acid and a sodic carbonate in the presence of water, whereupon sodium salicylate results, and remains in solu- tion, and carbon dioxide gas escapes in effervescence. From this solution the salt can be obtained by evapora- tion to dryness, carefully conducted. Extemporaneous preparation of the medicine in solution being easy, Squibb points out an advantage of such extemporaneous making of the salt in all cases in which the prescriber or the dis- penser may not be certain of the purity of the market article. The point is that it is not possible to establish the purity of a given sample of sodium salicylate except by an elaborate chemical analysis, whereas a good sam- ple of salicylic acid is immediately recognizable by the simple fact of its crystalline condition. Hence, in making one's own sodium salicylate from a selected well-crystal- 8 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Salicylic Acid. Sallcyl-Sulplionlc Acid, lized sample of salicylic acid, purity is assured. And in the instance of this salt purity is important, since, as above said, there is probably good reason to lay many of the untoward effects of salicylates to the door of the con- taminating acid of salicylic acid. Squibb recommends the following formula for the preparation of a solution of sodium salicylate of a strength convenient for use as a medicine: "Take of salicylic acid, well crystallized, 437 grains = 28.32 gm. ; bicarbonate of sodium, 270 grains = 17.5 gm. ; water, free from iron, a sufficient quantity. Put the acid into a vessel of the capacity of a pint, add 4 fluidounces = 120 c.c. of water, stir well together, and then add the bicarbonate of sodium in por- tions with stirring, until the whole is added and the effervescence is finished. Filter the solution, and wash the filter through with water until the filtered solution measures 6 fluidounees, or 180 c.c. This solution con- tains 10 grains ( = 0.65 gm.) of the medicinal salicylate of sodium in each fluidrachm ( = 3.75 c.c.). If made from good materials, the solution before filtration is of a pale, amber color, but as most ordinary filtering paper contains traces of iron, the filtered solution is often of a deeper tint." The proportions of the ingredients for this solution are estimated so that the solution shall be neu- tral, but, " owing to the varying proportions of hygro- metric moisture in the materials," the neutrality may not always be absolute. According to Squibb, a well-made sample of sodium salicylate, prepared by use of a well- crystallized sample of acid, is always, when evaporated to dryness, white, and is free from all odor of carbolic acid, unless it has been shut up for a long while in a bot- tle. Even then, however, the odor should be but very faint — only perceptible on close examination, and should disappear upon exposure of the sample to air. Solutions of sodium salicylate of good quality should have none of the carbolic-acid smell. Sodium salicylate is used almost exclusively as an in- ternal medicine, being commonly held to be lacking in the germ-sterilizing faculty which gives salicylic acid, as such, its applicability as a local antiseptic. For the purposes of internal salicylate medication, as set forth above, the salt is thoroughly effective, and, if made from a well-crystallized and therefore fairly pure sample of salicylic acid, rarely produces untoward effects in reason- able doses. So large a quantity as 5 gm. (about seventy- seven grains) has been given at a single dose in rheuma- tism without producing serious derangement, but the ordinary dosage for an antipyretic or antirheumatic effect does not exceed 1.8 gm. (20 grains) repeated every two hours, for three or four doses, or until a distinct impres- sion is produced, followed by doses of half the quantity every hour or two thereafter, so long as the influence of the medicine may be required. The medicine is readily enough taken in simple aqueous solution, but if the faint, mawkish taste of the salt be objectionable, the ad- dition of twenty per cent, of glycerin and the flavoring with a drop or two of oil of gaultheria will render the mixture perfectly palatable. Lithium Salicylate, 2LiC,H 3 .H 2 0. The salt is offi- cial in the United States Pharmacopoeia under the title Lithii Salicylas, Lithium Salicylate. It occurs as a whit- ish powder which deliquesces on exposure to the air. It dissolves freely in water and alcohol, and resembles the sodium salt in taste. . It should be kept in well-stoppered bottles. The effects of this salt are similar to those of sodium salicylate, with the possible superaddition of medicinal virtues, in rheumatic or gouty cases, derived from the basic element. The dose is similar to that of the sodic salt. Methyl Salicylate, CH S C,H 6 3 . This salicylate is an ethereal body which constitutes nine-tenths of the sub- stance of oil of wintergreen and practically the whole of the volatile oil of betula, both of which oils are them- selves official medicines. Under the title, however, Methyl Salicylas, Methyl Salicylate, the United States Pharmacopoeia recognizes the salicylate as made in the laboratory by distilling salicylic acid or a salicylate with methylic alcohol and sulphuric acid. Methyl salicylate is a colorless or slightly yellowish liquid, with the char- acteristic odor and taste of oil of wintergreen. It dis- solves freely in alcohol. It should be kept in well-stop- pered bottles protected from light. Methyl salicylate acts like the salicylates generally, with the usual pungent qualities of the volatile oils. In large doses — half an ounce or more — it is dangerously and even fatally poison- ous, causing intense irritation of the stomach and intes- tines with constitutional symptoms of the salicylic influ- ence. In doses of from five to fifteen minims it makes a very efficient salicylic medicine for rheumatism, and is, with many, the favorite salicylate. It may be adminis- tered in emulsion or in capsules. Sodium Dithio-salicylate. Dithio-salicylic acid is a product of reaction between salicylic acid and sulphur chloride, under the influence of heat. The sodium salt of this product is a grayish- white, very hygroscopic pow- der, freely soluble in water. It has been proposed as a substitute for ordinary salicylates, on the score of being equally, if not more, potent as an antirheumatic remedy, while it is less apt to disturb the stomach: About 0.2 gm. (gr. iij.) may be given two or three times a day, or oftener, according 1o indications. It is not official in the United States Pharmacopoeia. lodo-salicylic Acid is a modification of salicylic acid that has been used as a substitute for the ordinary acid in acute rheumatism. It occurs as a white powder slightly soluble in water, but freely so in alcohol, ether, and the fixed oils. It may be given in quantities of from 1 to 3 gm. (gr. xv. to gr. xlvi.) a day. Cresotic Acid, Cresotinic Acid. — This is an homologue of salicylic acid to which it is allied in physical, chemi- cal, and physiological properties. Its formula is C 6 H 3 - OHCH3COOH. There are three isomeric acids, the ortho-, meta-, and paracresotic acids. They are always present in salicylic acid of commerce. In 1890 (Phar. Jour, and Trans. , November 22d) Professors Charteris and Dunstan, of Glasgow, pointed out that the ill effects that often followed the employment of salicylic acid were due to the presence of ortho- and paracresotic acids. These statements were described more in detail in a second paper in the British Medical Journal, March 25th, 1901. The only preparation of this acid that has been em- ployed for therapeutic purposes is the paracresotate of sodium. It posseess antipyretic and antirheumatic properties similar to those possessed by salicylate of soda, but in a lesser degree. The dose is from five to twenty grains three or four times a day ; it is free from toxic action, and may be administered more freely if nec- essary. Edward Curtis. SALICYLIC ALDEHYDE, salicylous acid, ortho-oxy- benzaldehyde, artificial oil of spiraea, CelL.OH.COH, is obtained by heating phenol and sodium hydroxide with chloroform. A colorless fluid with the odor of meadow- sweet, it is readily soluble in alcohol and chloroform, but in water is soluble only enough to impart its odor. In dose of 0.1-0.5 gm. (gr. iss.-viiss.), it is employed as a diuretic and intestinal antiseptic. W. A. Bastedo. SALICYLIDEN-PHENETIDIN. See Malakin. SALICYLO-ACETIC ACID. See Aspirin. SALICYL-QUININE. See Saloquinine. SALICYL-QU1NINE SALICYLATE. See Bheumatin. SALICYL-RESORCIIM-KETONE, tri - oxy - benzophe- none, is a compound which in the intestine sets free sali- cylic acid and resorcin. It is used externally in skin diseases, and internally as an intestinal antiseptic. Dose, 3-4 gm. (gr. xlv.-lx.). W. A. Bastedo. SALICYL-SULPHONIC ACID.— CH 3 (OH) (S0 3 H)- COOH. A white crystalline body, very soluble in water and alcohol. It is formed by the action of sulphuric anhydride on salicylic acid. Sallfebrln. Saliva. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. This compound was recommended as a test for albumin by G. Roch (Pharm. Uentralblatt, September, 1889) and by Dr. John A. Macwilliam (British Medical Journal, April 18th, 1891), working independently of each other. It acts upon all forms of proteid bodies. When the proteid present is a native albumin, a derived albumin, a globulin, or fibrin, the precipitate is not dissolved upon boiling, but becomes decidedly flocculent. When the proteid is an albumose or peptone, the precipitate dis- solves upon heating, to reappear on the cooling of the fluid. The peptone and albumose may be distinguished by saturating the solution with ammonium sulphate ; the albumose is at once precipitated, while the peptone re- mains in solution. The peptone may then be detected by adding the salicyl-sulphonic test. Compared with other tests, the delicacy of the salicyl- sulphonic test varies, according as a cloudiness immedi- ately (two or three seconds) appears, or follows after one-half to one minute. In the latter case it is one of the most delicate tests we possess, revealing the presence of 1 part of albumin in 12,500 of water; in the former, it is placed by Dr. Macwilliam between the cold nitric acid test and the acetic acid and heat test. Dr. Roch recommended that a few crystals of the acid should be shaken with the urine, or that 5 c.c. of a twenty-per-cent. solution should be added to 10 c.c. of the urine to be tested. Dr. Macwilliam is more exact in his manipulations. He recommends that a small amount of urine, about twenty minims, be placed in a small test tube, and that to this a drop or two of a saturated aque- ous solution of the reagent be added. The urine must not be alkaline, and, if necessary, it should be acidulated. On adding the reagent the tube should be shaken quickly, to mix the contents, and the fluid should be examined at once. The occurrence of an opalescence or cloudiness immediately or within a few seconds indicates the pres- ence of proteids. The development of the reaction after an interval of a minute or two shows the presence of proteids in minute quantities, which are probably insig- nificant from a clinical point of view. The fluid is then to be heated, when the ordinary albumin is coagulated and formed into a flocculent mass. Beaumont Small. SALIFEBRIN, salicylanilid, is a proprietary combina- tion of acetanilid and salicylic acid. W. A. Bastedo. SALIFORMIN, urotropin salicylate. See Vrotropin. SALIGALLOL, the di-salicylate of pyrogallic acid, is a resinous substance, soluble in chloroform or acetone. Kromayer finds that it has but a weak pyrogallol action, but is of value for the preparation of an excellent skin varnish which may serve as a vehicle for other medica- ments. " Solutio saligalloli " is a sixty-six-per-cent. solu- tion of saligallol in acetone. W. A. Bastedo. SALINE SOLUTION, NORMAL. See Eypodermoelyiis. SALINS-MoCtiERS. See Brides-les-Bains. SALIPYRIN. — A compound containing 57.7 parts of antipyrin and 43.3 parts of salicylic acid. It is pre- pared by adding to a boiling aqueous solution of antipy- rin a proper molecular proportion of the acid. It forms as a white, coarsely crystalline powder, odorless, with a not unpleasant sweetish taste. It is almost insoluble in water, about one part in two hundred, sparingly solu- ble in ether, but readily soluble in alcohol. It is decom- posed by acids and alkalies. It possesses antipyretic and antirheumatic properties, and was introduced as a substitute for the salicylates in the treatment of rheumatic affections. It is probably as serviceable as salicylic acid or antipyrin, but is equally inefficient in preventing relapses, and does not seem to offer any special advantage over other remedies for rheu- matism. The amount to be given is one drachm and a half, in divided doses, during the day ; the first dose be- ing thirty grains and the subsequent doses about fifteen . grains each. ' As an antipyretic it is not very satisfactory ; it re- quires to be given in doses of thirty grains, to be repeated every hour if necessary. As an analgesic it has proved of value in sciatica, in the pains of myelitis, in neuralgia, and in nervous disease accompanied by pain. The results of its employment show it to be a harmless and useful drug, but not very reliable. It has not su- perseded either of its. component parts. Profuse per- spiration and gastric disturbances frequently follow its employment. Beaumont Small. SALITANNOL, C4H10O7, is a condensation product of salicylic and gallic acids, forming a white, amorphous powder. It is insoluble in water, ether, chloroform, and benzol, slightly soluble in alcohol, and readily soluble in solutions of the caustic alkalies. It is employed surgi- cally as an antiseptic. W. A. Bastedo. SALITHYMOL, CeH3.CH s .C 8 H 7 .O.COC 6 H 4 OH, is a combination of thymol and salicylic acid somewhat simi- lar to salol. It is obtained by acting with phosphorus trichloride on equimolecular quantities of the sodium compounds of salicylic acid and thymol, and then crys- tallizing from alcohol. Salithymol is a white crystalline powder of mild sugary taste, very soluble in alcohol and ether, and nearly insoluble in water. Its uses are those of salol, but it is claimed to be preferable, as it sets free thymol in the intestine, while salol liberates phenol. The dose is 0.3-1 gm. (gr. v.-xv.). W. A. Bastedo. SALIVA. — The saliva is formed by the admixture of the secretions of the three pairs of chief salivary glands, viz., the parotid, submaxillary, and sublingual, and of the small buccal glands. The mechanical and chemical functions of the saliva in connection with deglutition and digestion have already been considered in the articles upon these subjects, and hence the secretion and chemical composition of the fluid only need be taken up in this article. Secretion. — The three paired salivary glands form typi- cal examples of racemose, tubulo-saccular secreting glands. Each gland possesses a main duct by which the secretion is carried to the mouth. Within the gland this duct divides and subdivides in a racemose fashion, giv- ing rise finally to a large number of minute ductules lined by a single layer of columnar cells. Each ductule, as it passes toward the secreting cells, divides, and the cells lining the secondary ductules so formed become flattened in shape ; then each secondary ductule widens to form a tube of secreting cells, which usually possesses branches also lined with similar secreting cells, which may again branch and be lined with secreting cells in similar iashion. Thus a racemose clump of secreting tubules is formed around the end of each ductule. These secreting tubules are termed alveoli or acini, and are lined by polyhedral cells which surround in a single layer a minute central cavity or lumen, into which the secretion is poured when the gland becomes active. This layer of secreting cells is sheathed externally by a thin basement membrane, and lying upon this is a network of fine capillary blood-vessels for the nutrition of the se- creting cells. The lymph exuding from this capillary plexus bathes the secreting cells after it has passed through the fine basement membrane, and the cells tak- ing up the lymph, even during periods of rest, transform its constituents into defiuite chemical substances which are stored up in the cells in such a manner as to be visible under the microscope as minute granules. _ When the gland becomes active as a result of stimula- tion in the natural fashion, two important changes, which have been shown to be independent of each other in their innervation, occur: in the first place, the vaso-dilator fibres supplying the walls of the blood-vessels of the gland are stimulated, so giving rise to an increased blood supply, and hence to an increased flow of water and salts to the secreting cells to serve as a vehicle for carry- ing off those cell products which have accumulated in the cell during the period of intermission in secretion- in 10 REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. Salil. brill. Saliva. the second place, the gland cells themselves are directly stimulated by the secreto-motor fibres to a change in ac- tivity, as a result of which the granules deposited previ- ously in them undergo a chemical modification which renders them soluble and easily transported through the cell into the lumen of the alveolus. The constituent al- veoli are bound loosely into small masses visible to the naked eye, which are termed lobules, and these lobules are divided off from one another, and at the same time united to form the gland mass, by coarser bundles of con- nective tissue, which unite at the outer surface of the gland to form a capsule, varying in the clearness of its definition in the different glands and in different animals, being usually but ill-defined in the case of the parotid gland. The secreting cells of the salivary glands when observed under the microscope, either in the fresh state or after the use of hardening and staining reagents, present two distinct types of characteristically different appearance, and each type again shows distinct modifications in ap- pearance according to whether it is observed at a period of fasting (loaded) or during a period immediate^ fol- lowing digestive activity (unloaded). These differences in type correspond to a difference in chemical character of the secretion yielded by the re- spective cells, for it has been shown that one form of cell secretes the mucin of the saliva, while the other secretes the ptyalin, which confers upon the saliva of certain mam- mals, including man, its important chemical action upon the starch of the food. (See Digestion.) The relative extent to which the two cells are devel- oped in the corresponding glands of different animals varies within very wide limits, the same gland being al-. most completely composed of one type in one animal and of the other type in another. In many cases the same gland contains both types of cells, as is particularly well seen in the human submaxillary gland, and in such a case the different characters of the two types of cell can be studied side by side in the same section. Usually the cells occupying any one alveolus are of the same type, either mucous or serous ; but in the mucous alveoli a third type of cell occurs, lying outside the true mucous cells, between these and the basement membrane. From their position and the pressure applied to them by the con- centrically arranged cells of their own alveolus on one hand and the adjacent alveoli on the other, these cells as they develop become crescentic in shape and have hence been termed demilune cells. In a mucous alveolus, the mucin-secreting cells present in hardened sections a perfectly clear, homogeneous, glass-like appearance, except for the nucleus, which is usually shrunken and lies at the broader end of the cell close to the basement membrane. This appearance is, however, an artifact, and is due to the action of water, alcohol, or other reagent used in the process of manipula- tion, upon the cell contents ; for these mucous cells when examined in the fresh state, teased out in blood serum, are filled up, provided the gland is in the loaded state, by large granules which are stated to be composed of muci- nogen, a precursor of the mucin found in the saliva. On the other hand, if the gland has been much stimulated before the mucous cells are taken for examination, it is found, according to the degree of stimulation, that these mucinogen granules may either be few in number and confined to the inner zone of the cell, or may be entirely absent. In the process of secretion, then, the mucinogen granules are dissolved, being converted into soluble mu- cin, which is carried by the stream of water and salts through the mucous cell toward the lumen of the alve- olus, and is thence discharged into the duct. Supporting this view, there is the fact that the viscidity and amount of mucin present in the saliva vary with the amount of these clear cells present in the gland. Various contentions have been put forward as to the nature and purpose of the demilune cells present along- side the mucous cells in the same alveolus, and present also in glands containing no serous alveoli. These cells differ strikingly in histological appearance from the mucous cells, especially in hardened and stained sections, being not only different in shape and position, as above described, but also smaller, free from mucin granules, and filled instead in the loaded condition with minute highly retractile granules similar to those present in the serous cells (vide infra) and disappearing during secretion. One view was that they were young mucous cells de- signed later to be pushed toward the lumen and take the place of mucous cells which had broken down in the process of secretion. There is, however, no good evidence that the mucous cells are disrupted in the process of discharge ; no inter- mediate stages in the process of conversion of demilunes into mucous cells have ever been demonstrated; and, further, the charged and discharged condition of the demilunes as regards their granules, varying as it does concurrently with the state of the gland, proves that they are functionally active and not immature growing cells. The view has hence been put forward that these demi- lunes are really serous cells, occurring in chiefly mucous glands and not differing save in shape from the other se- rous cells which constitute the chief cells in other alveoli. Their peculiar shape can be explained from their posi- tion, while the fact that ptyalin in addition to mucin is also found in the secretion of glands containing otherwise only mucous cells points strongly to the demilunes being serous cells. The cells of the serous or albuminous alveoli in the loaded condition are filled with minute highly ref ractile granules which render the cells opaque, disguise the nu- clei, and make it difficult even to discern the cell out- lines. When the gland is stimulated to secrete, these granules rapidly decrease in number, the cell outlines be- come clearly marked, soon the nuclei become visible, and the outer zone of the cell clear of granules, and capable of staining with dyes, while the portion of the cell tow- ard the lumen is still loaded with granules. As secretion is pushed to the extreme limit, this luminal zone, how- ever, becomes smaller and smaller, showing that there is a current of dissolution setting toward the lumen. The intrinsic ferment of the saliva is yielded by these cells, but it is probable, as in the case of the pancreas (q. v.), that the ferment is not deposited in the cells in the form of this ferment in the granular condition, but is in- stead present in the cells in an inactive form called ptya- linogen, from which the free ptyalin is formed as solution of the granules takes place in the act of secretion. In | some animals, however, as has been shown in the case of ' ! the horse, the active ferment is set free in an unknown \' manner only in the mouth, and not in the gland itself, t For if the parotid saliva of the horse be collected, by means of a fine sterilized glass cannula inserted into Sten- son's duct, in sterilized glass vessels, it is quite inactive) upon starch solutions, and first becomes active when it isj agitated by blowing air through it. Each salivary gland is innervated along two distinct paths, receiving nerve fibres, on the one hand, from the medulla oblongata by a cranial nerve, and, on the other, fibres from the spinal cord through tne cervical sympa- thetic. These nerve fibres have two distinct functions, some passing to the blood-vessels of the glands and regu- lating its blood supply, while others are purely secretory in character and pass to the secretory cells of the alveoli. The greater number of the secretory fibres are carried by the cranial nerves and are there accompanied by the vaso-dilators ; while a smaller number of secretory fibres, which seem especially to be connected with the secretion of the organic constituents of .the saliva, pass to the gland via the cervical sympathetic accompanied by the vaso- constrictor fibres to the blood-vessels. The cranial fibres for the submaxillary and sublingual glands are carried by the chorda tympani, which leaves the facial nerve in the Fallopian canal, crosses the tym- panum, and then joins the lingual branch of the fifth. The lingual nerve gives off a branch at the posterior bor- der of the submaxillary gland, which contains the ma- 11 Saliva. Salivary Glands. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. jority of the fibres which had joined previously by way of the chorda tympani, and this branch, which consists of a number of strands lying close together, contains most of the secreto- and vaso-motor fibres for the submaxillary and sublingual glands. These strands, often wrongly called the chorda tympani nerve, curve backward along the gland ducts and pass with them into the glands. The cranial fibres for the parotid gland vary in their course in different animals, but frequently they arise from the ninth cranial nerve and course in the nerve of Jacob- son, across the tympanic cavity, over the promontory of the tympanum, and pass via the small superficial petrosal and otic ganglion to the auriculo-temporal branch of the fifth, by which they are finally distributed to the parotid gland. The sympathetic fibres to the salivary glands arise from the spinal cord in the upper dorsal region and run to the superior cervical ganglion, where a relay of nerve cells is interposed, round which the original fibres arising from the spinal cord end in arborizations. From the nerve cells of the superior cervical ganglion other fibres arise, chiefly from the lower and middle portion, and, passing to the external carotid, form plexuses upon it and its branches by which the fibres are ultimately carried to the gland without forming any more nerve-cell connections. A similar cell station has been demonstrated in the case of the chorda tympani fibres, as lying in the many small ganglia between the point at which the fibres leave the lingual nerve and the various points at which the fibres enter the glands. These ganglia are as a rule microscopic in size, but two can be seen with the naked eye and have been named, viz., the sublingual, lying in the angle between lingual and chorda, which is a cell station for fibres passing to the sublingual ; and the submaxillary, which lies in the hilus of the submaxillary, and forms a cell station on the path of many of the fibres for that gland. The position of these various cell stations has been demonstrated by Langley by the injection of small doses of nicotine, which paralyzes the junction between nerve fibre and nerve cell, but does not affect the nerve fibres. Hence the. position of a nerve station is shown after injection of this drug into a vein, if no effect is now ob- tained on stimulating centrally to a ganglion, while an effect is still obtainable peripherally to the ganglion, pre- vious experiment before injection of the drug having given an effect at both places. Experimenting by this method, Langley has shown that every fibre leaving the spinal cord, whether by cra- nial nerve or sympathetic, ends somewhere on its course in a peripheral ganglion. Such a fibre is termed a pre- ganglionic fibre. From the peripheral ganglion cell a fibre arises which is termed a postganglionic fibre, and this without further interruption passes to distribution in the gland. There is hence in every case one ganglion cell and no more interposed between spinal cord and gland. The preganglionic fibres are in most cases finely medullated (2 to 4 fi), while the postganglionic fibres are probably all uon-medullated. The effect of stimulation upon the nerves has been most closely studied in the case of the submaxillary nerve, but similar results have been obtained by stimula- tion of the corresponding nerves in the other glands, so that a description of the occurrences in the case of the submaxillary may be taken to hold for the other two glands. Excitation of the peripheral end of the cranial nerve (chorda tympani) causes, after a very short latent period, a rapid flow of a very dilute saliva, containing a very low percentage of organic constituents. Even weak stimulation produces a copious flow, and secretion can be evoked in this manner for a long period without fatigu- ing the nerve, so that a quantity amounting to forty or fifty times the weight of the gland can be obtained. Accompanying this rapid secretion there is a marked vaso-dilatation, so that the gland can be seen to become much pinker to the naked eye, and when placed in a plethysmograph shows a large increase in volume. That the increased flow of saliva is not, however, solely due to an increased blood supply is demonstrated by the following facts: 1. After administration of atropine, the flow of saliva is no longer obtained, although the vaso-dilatation is as great as before, showing that atropine paralyzes secreto- motor fibres but leaves the vaso-dilators untouched. 2. If the cannula placed in the duct of the salivary gland be connected up to a mercurial manometer, and at the same time the carotid blood pressure be similarly ob- served by means of a second manometer, it is found that the flow of saliva does not stop until the pressure in the salivary manometer has risen considerably higher than that in the carotid. Now, if the secretion were merely an increased filtration due to increased blood supply, this obviously could not be so, for then the saliva would be filtering from a lower to a higher pressure. These experiments are sufficient to show that a true se- cretion is taking place in the alveolar cells, under the stimulating influence of a secreto-motor nervous mechan- ism distinct from the vaso-dilator mechanism. The effects of stimulation of the cervical sympathetic upon the gland are very different ; there is a vasocon- strictor instead of a vaso-di)ator effect, and, after a much longer latent period, there is but a scanty flow of a very viscid saliva much richer in organic constituents. The amount of flow caused by stimulation of the cer- vical sympathetic is considerably increased if the cranial nerve has been stimulated a few seconds previously. Now in the natural stimulation of the gland, as by the sight or thought of food, or by the act of mastication, it is a fairly obvious conclusion that both cranial and sympa- thetic nerve supplies act upon the gland simultaneously, and hence that there will be conjoined the greater flow of water and inorganic salts caused by the cranial nerve fibres, with the stimulation to increased flow of organic substances effected through the cervical sympathetic fibres. No saliva flows between periods of stimulation, and it has been observed by inserting a cannula into the duct of Stenson in the horse that a flow of saliva occurs only when it is provoked reflexly, as by mastication. Cutting the cranial nerve gives rise to the so-called "paralytic secretion," first observed by Claude Bernard; this commences commonly in from two to three days after the section, and lasts for a period of three or four weeks, during which time there is a constant slow secretion ac- companied by a great decrease in weight of the gland, which finally becomes f unctionless. No permanent effect of a like nature follows section of the cervical sympa- thetic. It is interesting that a much slighter flow accompanies the paralytic secretion, upon the opposite side where the nerves are quite intact ; this peculiar secretion is spoken of as "antilytic secretion." There is no explanation of either paralytic or antilytic secretion, outside the region of mere hypothesis. The mouth is probably kept moist in man between the periods of eating by the secretion of the small buccal glands, for it has been shown that the secretion of the large glands completely intermits between the meals in cases of artificial fistula; of the gland ducts. In man, the sight or even the thought of appetizing food causes an immediate flow ; but secretion cannot be evoked in this fashion in some of the lower animals. Thus presenting meat to a dog in which a parotid fistula has been established does not cause a flow of saliva. Sapid substances are the most powerful reflex stimu- lants to secretion when placed either on the tongue or on the mucous membrane of the mouth. The vapors of chloroform and ether cause a rapid se- cretion when inhaled by the mouth, as a result of the stimulation of the gustatory nerve endings; when ad- ministered by the trachea, they are said not to produce this effect. Alcohol, or water containing chloroform or ether, ap- plied to the mucous membrane of the mouth, causes a rapid secretion. The sapid substances produce their effect in the follow - 12 REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. Saliva. Salivary Glands. ing descending order of strength: (1) acids, (2) neutral and alkaline salts, (3) bitter substances, (4) sweet sub- stances ; but the acids (including organic acids) are in- comparably more effectual in evoking secretion than the other classes of sapid bodies. Chemical Composition.— The composition of the mixed saliva is very variable, as can readily be understood when it is considered how many glands contribute to its forma- tion. Sublingual saliva is richest in solids, and may con- tain as much as three per cent. ; submaxillary saliva is stated by most observers to contain a higher percentage of solids than the mixed saliva, while parotid saliva is poorest in solid constituents (0.3 to 0.5 per cent.). The total solids of mixed saliva amount to from 0.5 to 1 per cent., and the specific gravity lies between 1.002 and 1.008. Mixed human saliva is alkaline to litmus and acid to phenolphthalein, indicating that there is an excess of carbon dioxide present above that necessary to form so- dium bicarbonate. This is borne out by the large amount of carbon dioxide obtainable from saliva, which contains more of this gas than either blood serum or venous blood. Thus Kiilz found in saliva 66.7 volumes of CO a per 100, and Pfliiger 64. 7 to 85. 1 volumes per 100. This fact is of interest as showing the large amount of metabolism which occurs in the secreting cells, and lends a further proof, if such were necessary, that the process of secretion is not purely one of filtration and osmosis. The average amount of alkalinity to litmus is equivalent to that of a solution of 0.08 per cent, of Na 2 C0 3 (Chittenden and Ely). The organic matter of the saliva is small in total amount, and is present partially in suspension, as formed elements and partially in solution. The formed elements present include squamous cells from the buccal epithelium, salivary corpuscles, and very pale spherules resembling the granules seen in the mu- cous salivary cells. The salivary corpuscles are altered leucocytes derived chiefly from the salivary glands, but possibly the tonsils also contribute to their number. The leucocytes pass from the lymph, between the alveolar cells, into the ductules, and become swollen out by imbibition from the saliva, which has a lower osmotic pressure than the lymph. For the same reason the granules which these corpuscles contain are set in active Brownian movement. The chief organic substances in solution are mucin, ptyalin, and minute traces of proteid. The mucin can be demonstrated by its precipitation on the addition of acetic acid. The presence and action of ptyalin have been considered in the article on Digestion. Coagulable proteid is present only in minute traces. Urea is said to be excreted in the saliva in uraemia, and lactic acid in diabetes. Saliva normally gives a distinct reaction for sulphocy- anides when a very dilute solution of ferric chloride is added to it. The test is best carried out by wetting filter paper with ferric chloride so dilute as scarcely to color it, and then adding the saliva, when a red color is ob- tained. Sulphocyanates are, however, absent in certain individuals, and in the same individual are present at certain times and absent at others. The inorganic salts present consist chiefly of chlorides, phosphates, and carbonates of the alkalies and alkaline earths, the chief constituent as usual being sodium chlor- ide. The most interesting of the inorganic constituents is calcium bicarbonate ; it is this salt which gives rise to the cloudiness observed when saliva is allowed to stand for some time. The precipitation is due to the escape of . the excess of carbon dioxide, which had previously held the calcium carbonate in solution. A certain amount of calcium phosphate is similarly precipitated. Such a precipitation occasionally leads to occlusion of the gland ducts by the formation in these of salivary concretions, which consist of a mixture of calcium carbonate and calcium phosphate. When the precipitation occurs on the teeth it is termed tartar ; this also contains silica in addition to the calcium salts mentioned above. Benjamin Moore. SALIVARY GLANDS AND THEIR DUCTS, DIS- EASES OF. — Increased Secretion of the Salivary Glands (Ptyalism; Salivation). — The normal amount of salivary secretion is from one to three quarts in twenty-four hours, though under exceptional conditions the quantity may be as much as five quarts. While food is being taken the saliva is normally greatly increased, which may also occur during the menstrual period and during gestation. Salivation, likewise, occurs in connection with quite a number of different diseases, such as acute fevers, dis- eases of the liver, spleen, genital organs, and pancreas, and in all inflammatory conditions of the oral cavity. It is likewise sometimes seen in bulbar paralysis, in diabetes, and in melancholia. Quite a number of drugs are also capable of giving rise to an increased salivary secretion, among which are muscarin, tobacco, pilocar- pine, potassium iodide, the salts of arsenic and copper, and mercury and its various compounds. Of all the causes the last mentioned is the one that most frequently occasions the condition, and it is true that the amount necessary to produce this result varies very greatly in different instances — some individuals tolerating large quantities of the drug, while others are affected by very minute doses. (For the treatment see article on Mouth, Diseases of, in The Appendix.) Decreased Secretion of the Salivary Glands (Xerostomia ; Dry Mouth). — The secretions of the salivary and buccal glands may be greatly diminished, or, in some instances, entirely suppressed. The condition is most commonly observed in nervous women, though it is occasionally seen in men as well ; it may follow shock or may occur in connection with diabetes and febrile states. As a nat- ural consequence of the arrest of the secretion the tongue and mucous membranes of the cheeks and palate become dry, and mastication and articulation are exceedingly diffi- cult. Osier speaks of a case observed by him in which, on account of the absence of the normal secretion of the mouth, food collected along the gums and became ex- ceedingly hard, presenting somewhat the appearance of a new growth in the oral cavity of the patient ; in this instance the affection was cured in about three weeks by the application of the galvanic current. Treatment. For dry mouth pilocarpine may be used, and, as in the case above cited, electricity may be em- ployed with advantage. Oils applied to the mucous membrane of the mouth are of service in ameliorating the very disagreeable dry state of the oral mucous mem- brane. The condition is very obstinate. Inflammation of the Salivary Glands. — There are several distinct and separate varieties of inflammations of the salivary glands at present recognized, and there can be no question but that, as our knowledge increases, many Conditions which are at present regarded as being identical will be found to be the result of causes differing widely from each other. There are specific parotitis (see Mumps), symptomatic parotitis, and chronic paro- titis. Symptomatic Parotitis. — Symptomatic parotitis is an affection that occurs in connection with a large number of different diseases, though the relationship between inflammations of the glands and the causes that appar- ently determine them are exceedingly obscure. The condition occurs most commonly during the course of the infectious fevers, such as typhoid, typhus, scarlet fever, rheumatism, pneumonia, peritonitis, pyaemia, sep- ticaemia, and syphilis, but it is also sometimes seen in connection with consumption and gout. When the affection results from acute fevers, the inflammatory phenomena are quite severe, and, as a rule, suppura- tion results. If the pus be not evacuated by surgical means, it not uncommonly burrows into the tissues of the face to a considerable distance. Inflammations of these glands likewise very curiously often follow lapa- rotomy, and operations upon the genital organs in both men and women. It has also been found associated with facial paralysis, and may occur during pregnancy or fol- low menstruation. 13 Salfx. Salsomagglore. REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. _ Treatment. Ice-bags should be applied in the begin- ning to relieve the pain, or leeches may be employed for the same purpose. Belladonna ointments are of some ser- vice during the acute inflammatory stages. When it is found that suppuration is likely to supervene, poultices should be applied, and at the first indication of sup- puration the glands should be incised and the pus evacu- ated. Chronic Parotitis. — Chronic parotitis, for clinical pur- poses, may be divided into two varietes: (a) the chronic inflammation of one or more of the glands, with or with- out history of previous acute disease, and (b) the curious inflammatory condition in all of the salivary and lachry- mal glands first described by Mikulicz. (a) Chronic Parotitis with or witJiout Previous Acute Inflammations of the Glands. — This affection is occa- sionally observed as a sequel of mumps, and may fol- low inflammatory conditions occurring in the throat. It has been observed in secondary and tertiary syphilis, in Bright's disease, and as a complication of chronic tuber- culosis of the lungs. Some years ago the writer de- scribed a case of this kind that occurred in connection with chronic inflammatory changes in the pancreas, in a man suffering from diabetes. The affection may be the result of lead or mercurial poisoning. Treatment. Except the condition be of syphilitic origin — in which case mercury and iodide of potassium should be employed — we know of no drugs that affect the course of this disease. (J) Chronic Symmetrical Inflammation of the Salivary and Lachrymal Olands. — Since the publication of the paper of Mikulicz, Kummel has reported a number of in- stances of this disease, and in this country Osier has re- cently recorded a very interesting example of the affec- tion. Nothing is known concerning the causation of this malady, but in Osier's case the patient had probably suf- fered from tertiary syphilis, and the enlargement of the glands gradually subsided under the use of mercury and iodide of potassium. Kummel found that the salivary glands are completely replaced by mononuclear leuco- cytes, and suggests the name of achroOcytosis. Osier's patient died later of tuberculosis, and at the autopsy the lachrymal glands were found to be represented by masses of fibrous tissue. Though all of the glands are usually involved, in some instances this is not the case. The swollen glands are painless and the disease generally per- sists for a number of years. It is of interest to note that it has in some instances rapidly subsided following acute fevers. Treatment. In cases in which the disease is secondary to syphilis the appropriate treatment for the latter affec- tion would, of course, be called for, and even in instances in which there is no history of this disease it would be wise to give the patient the benefit of the doubt and to test thoroughly mercury and iodide of potassium. Should these remedies fail, it is not likely that other means would be efficient. Tumors op the Salivary Glands. — Carcinoma, sar- coma, adenoma, fibroma, fibro-adenoma, chondroma, myoma, and lymphoma occasionally occur in these glands, though none of them are common. Of these tumors fibro-adenoma is perhaps the most frequent. The malignant neoplasms found in the glands generally belong to the epithelial type. In all instances in which the tumors show evidence of malignancy they should be immediately removed. Diseases op the Ducts op the Glands. — Calculi, consisting of carbonate and phosphate of calcium, are occasionally formed in the ducts of the salivaiy glands, and either they may be discharged or they may lodge in some part of the ducts ; they sometimes occasion a reten- tion of the secretions of the glands. Under these circum- stances an operation should, of course, be resorted to to relieve the condition. Occasionally the ducts become dilated in glass-blowers and in musicians; when this occurs, the distended ducts present the appearance of a tumor, and contain air which may be mixed with saliva and pus. Henry Fauntleroy Harris. 14 SALIX.— Willow. Saule blanc, Fr. Cod. — When it was official, this drug was defined by the United States Phar- macopoeia as "the bark of Salix alba L. and of other species of Salix (fam. Salicacem). " Salicinum now entirely replaces it in the Pharmacopoeia. The species named is the common European white willow, now quite extensively naturalized in North America. It is a large tree with, when old, a very thick, irregular trunk, dividing near the ground into several great limbs ; branches numerous, ascending, rather densely massed ; twigs slender, lightly attached to the branches, possessing a light-yellow or greenish-yellow bark and white soft wood ; young shoots, A. b. Fig. 4110— Salix Alba. A., Stamlnate ; B, pistillate. buds and the under surface of the leaves silky ; leaves numerous, alternate, with small lance-ovate stipules and short petioles; the blades two to four inches long and about half an inch wide, lanceolate, acute, whitish be- neath, finely serrate; flowers dioecious, in slender weak spikes, each in the axil of a small bract, appearing in early spring. Only the bark of the younger branches should be collected. Willow bark is "in fragments or quills, from one- twenty -fifth to one-twelfth of an inch (1 to 2 mm.) thick, smooth; outer surface somewhat glossy, brownish or yellowish, more or less finely warty ; under the corky layer green; inner surface brownish- white, smooth, the fibres separating in thin layers; inodorous; bitter, and astringent. Constituents.— Besides ordinary plant constituents, willow contains the following three glucosides: tannin, about ten per cent. ; salicin (which see), about two per cent.; helicin (C 13 H 10 O, + fH 2 0). The properties and uses of the drug depend almost wholly upon the salicin contained, and our article on the latter substance should be consulted. As an antiperiodic, the bark is employed in doses of an ounce or more, in the form of fluid extract, or, as is more common in domestic practice, a decoction or infusion. It is often used as a tonic in doses of about one-fifth or less of this amount, the powdered bark being often used for this purpose; also as an intestinal astring- ent. Salix has sometimes produced good results as an anthelmintic. The powdered bark was formerly con- siderably employed as a vulnerary, salicylic acid having REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. Sallx. Salsomagglore. now entirely replaced it for this purpose in medical practice. Allied Drugs. — The genus Salix contains about one hundred and sixty species, many of which have been em- ployed like S. alba. The plants fall naturally into two classes, the one characterized by the yellow, the other by the purple color of their young shoots. The latter are said to contain more salicin, sometimes above three per cent., the former more tannin. Populus L. is the botanical name of the Poplars, Pop- ples, CottOnwoods or Aspens, a number of which, both European and American, are used, in the form of their barks and leaves, as willow bark is used. These drugs contain the same constituent as the willows, besides the closely allied glucoside populin or benzoyl-salicin. The buds of P. balsaminifera L. and P. candieans Ait. are known as balm of Gilead buds. Their scales are thickly coated with a very pleasant balsamic scented oleoresin, which possesses mild aromatic, diuretic, ex- pectorant, and vulnerary properties. Henry H. Rusby. SALOL — CeHuCHsOa. Salol is the name given to the salicylic ether of phenol (carbolic acid). It is com- pounded of salicylic acid and phenol and represents sixty per cent, of the former substance and forty per cent, of the latter. It is official in the United States Pharma- copoeia under the title Salol, Salol. Salol is a white crystalline powder, melting at 43° C. (109.4° F.) into a colorless, oily fluid. It is nearly insoluble in water, but dissolves in alcohol, ether, and fixed oils. From its in- solubility in aqueous fluids it is practically tasteless in powder, but it has a faint aromatic smell. Salol is used as a substitute for the common salicylate salts, on the grounds that it is equally effective as a medi- cine, while at the same time, in medicinal doses, it is much less deranging to digestion on the one hand, and less productive of constitutional toxic effects on the other. It is insoluble in the fluids present in the stom- ach — whence the lack of gastric derangement in its em- ployment — but suffers solution by chemical decomposi- tion in the small intestine through the action of the pancreatic juice, resolving into salicylic acid and carbolic acid (phenol). Constitutionally, salol, in ordinary dos- age, has produced little disturbance beyond an occa- sional and trifling ringing in the ears. In experiment- ing, however, with a dosage exceeding 6 gm. (about a drachm and a half) distributed over the twenty-four hours, toxic symptoms have been observed, as might be expected, considering that the medicine is nearly one-half carbolic acid. Salol, taken internally, imparts to the urine of the subject the peculiar coloration seen after ingestion of carbolic acid, a phenomenon that may persist for several days after discontinuance of the medicine. The average medicinal dose of salol for an antirheumatic or antipyretic effect is from 0.6 to 1 gm. (gr. x. to xv.), given twice, or thrice, daily. A dosage reach- ing 8 gm. (about two drachms), in the course of a day, was followed, in one instance, by severe vomiting, gas- tralgia, and tinnitus. Salol may be taken dry upon the tongue, in powder, the dose to be washed down with a little water, or may conveniently be administered in pill form. Because of the fact that salol only gradually suffers resolution into its constituents, the substance makes a useful intestinal disinfectant in diarrhoea or typhoid fever. Salol should not be given when there is any disease of the kidneys, because of the carbolic acid of its constitu- tion. Edward Curtis. SALOL-CAMPHOR.— These two substances, when mixed in certain proportions, alter their physical state and become an oily, colorless liquid, insoluble in water, . freely soluble in ether, chloroform, and oils. It is pre- pared by adding twenty parts, by weight, of powdered camphor to thirty parts of salol, and warming gently until fusion is complete. It possesses the properties of its constituents, and is highly recommended as a stimulating antiseptic. Beaumont Small. SALOPHEN. — (Acetyl-para-amido-salol.) A patented compound which is, chemically, salol in which one atom of hydrogen in the phenyl group is replaced by the monivalent group N a H(CH a O). It occurs in minute, white, crystalline plates, insoluble in cold -water, very slightly soluble in hot water, soluble in alcohol and ether. Alkalies render it soluble, even in cold water. It is without taste or odor, and is neutral in reaction. Salicylic acid is present to the extent of fifty -one per cent. The acid secretion of the stomach has no effect upon it, but when it comes in contact with the pancreatic ferments it is decomposed into salicylic acid and acetyl -para- amido-phenol. The object in view in the production of this compound was to improve upon salol by combining with the salicylic acid a phenol compound which was perfectly harmless. It is recommended as a remedy for acute articular rheumatism in doses of sixty to seventy -five grains dur- ing the day, the usual dose being fifteen grains every three or four hours. It does not disagree with the stom- ach nor produce any toxic symptoms. Relapses and the ordinary complications are not prevented. Salophen has proved serviceable in neuralgia, sciatica, and other painful affections of the nerves. Reports of its favor- able use in severe attacks of pruritus have been published. It has also been used with success in influenza. Beaumont Small. SALOQUININE, the quinine ester of salicylic acid, CeHi.OH.CO.O.CaoHjsN^O, is a mild substitute for qui- nine with added analgesic properties. Its advantages, as stated by Overlach, are that it has no disturbing effect upon the digestive or urinary organs or the nervous sys- tem, does not produce cinchonism, and is tasteless. He employed it in sciatica in 2 gm. (gr. xxx.) doses with good effect. Tauszk has used it in supraorbital neural- gia, influenza, the pains of locomotor ataxia, muscular rheumatism, acute articular rheumatism, and typhoid fever. He recommends it as an efficient antineuralgic with mild antipyretic action. In doses of 0.5-3 gm. (gr. viij.-xlv. ) daily, no vertigo or tinnitus was com- plained of, though in some cases mild sweating was ob- served. Fitch, Sternberg, and von Kolozsvary speak highly of its use in malaria, large doses 0.3-1.3 gm. (gr. v.-xx.), being administered several times a day. Being free from taste it is easily taken by children. The salicylate of saloquinine is "rheumatin.'' W. A. Bastedo. SALSOMAGGIORE, ITALY.— This new cure resort is pleasantly situated in Northern Italy, Lat. 44° 48' N., Long. 27" 38' E., two hours' ride by rail south from Milan. It lies in the valley of the Po, surrounded by low hills covered with the vine, maize, and mulberry trees. To the south rises the Apennine range. The village itself is picturesquely situated at an eleva- tion of about 500 feet, and contains 1,200 inhabitants. It is said to be unusually healthy, and is well supplied with good drinking-water. The climate is temperate, the heat being never uDduly excessive, and the sun is hidden by the hills before five o'clock in the summer. The country round about is very attractive and affords many interesting excursions either by road or by rail. From here Bologna, Parma, Modena, and other spots of interest are readily reached by rail. The accommodation is excellent, there having been opened in 1900 "The Grand Hotel des Thermes," with three hundred rooms and fitted with all modern equip- ments in the way of sanitation and comfort. There are music, billiard, and reading-rooms, elevators and elec- tric lighting, and the baths can be taken in the hotel itself, each floor being provided with special bathrooms 15 SalvitorMiu/s'pr'ss. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. for that purpose. The charges are not excessive. The season extends from April 1st to November, although July and August are the least desirable months in which to visit the spa. Salsomaggiore is one of the two best-known spas in Italy, the other being Bagni di Lucca. The waters are what are known as muriated iodobromine, locally called "salso-iodic," and are furnished by numerous artesian wells. Their natural temperature is 57.2° F. For the "cure" either the "salso-iodic" or the mother water, made by extracting the salt by evaporation, is employed. The analysis of the water is as follows : In 1 Kgm. op Watek from Salsomaggiore there is: Gm. Potassium cbloride. . . 0.000 Sodium chloride 153.990 Lithium chloride 735 Ammonium chloride . . .637 Calcium chloride 15.848 Strontium chloride . . . .256 Magnesium chloride.. 5.584 Iron chloride 033 Aluminum chloride Magnesium chloride. . . Magnesium bromide. . . Iodide of magnesium. . Borate of magnesium.. Bicarbonate of iron . . . Sulphate of strontium. Silicate Gm. 0.0590 .0057 .3037 .0663 .0116 .0778 .6033 Hot baths, mud baths, and inhalations are used in the treatment, which occupies from two to three weeks. The temperature of the baths is from 95° to 98.6° F., and the salso-iodic water is generally employed, although salso-iodic water mixed with the mother water can also be used. The duration of the baths is from fifteen to sixty minutes, and after the bath the patient goes to bed and rests. It is recommended that the cure be repeated again during the year, and followed up for two or three years. An after-cure in the mountains is advised. There is an inhalation hall where this method of treat- ment is pursued for various affections of the respiratory tract, such as bronchitis, pharyngitis, laryngitis, etc. ; for chronic eye affections, such as conjunctivitis, iritis, and keratitis ; and for certain skin diseases. The diseases lor which the baths are recommended are chronic rheuma- tism and gout ; various gynaecological affections, such as metritis, salpingitis, ovaritis, perimetritis, and sterility; anaemia ; convalescence from protracted illness ; infantile rachitis; neurasthenia; bone and joint tuberculosis; ter- tiary syphilis, and some forms of neuralgia and neuri- tis. Massage and Swedish gymnastics, electricity, and various forms of douches are also employed. The mud baths, which are given in conjunction with and apart from the baths, are used especially for rheumatoid arthritis. The mud obtained from the deposit of the tanks at the well (rich in salt, iodine, bromine, lithium, and petroleum), is applied to the affected parts as hot as can be borne, and is left on for about twenty minutes. It is then removed and generally followed by a bath of medicated water. Besides the arrangements for baths in the "Grand Hotel," there are bathhouses (staMlimenti) where every precaution is taken as regards cleanliness, sanitation, and disinfection. All laundry linen is carefully disinfected and sterilized after being used. Salsomaggiore can be reached from London in about thirty hours. In going from Milan to Florence one alights at Borgo San Domino, and takes a half-hour's ride in a branch train to Salsomaggiore. For a charming description of the excursions about this spa, one is referred to " Salsomaggiore and Its Sur- roundings," by Lady Colin Campbell. Edward O. Otis. SALT LAKE CITY, UTAH.— This city and the great region of the Salt Lake basin deserve consideration as a health resort of no mean degree, particularly as a place of residence for the consumptive. This basin of a former freat inland sea, a huge remnant of which is the existing alt Lake, has an average elevation of 4,300 feet, and is bounded on the east by a range of mountains and on the west and south by a desert. It is, then, a plateau of moderate elevation fed by the pure air from the moun- tains and the desert, and possessing a " maritime " quality from the presence of such a large body of salt water as the great Salt Lake, which covers an area of 2,360 square miles. Such an elevation, moreover, gives the peculiar climatic conditions incident to height above sea-level. The air is pure, cool, and dry ; the sensible temperature is not oppressive, on account of the dryness of the atmos- phere ; the rainfall is small ; high winds are absent, and the sunshine is abundant. Further, the softness of the air is a striking feature, very evident to one who first sets foot in this region, and giving a delightful sense of rest- fulness. The principal place of importance and resort is Salt Lake City, latitude 40° 45' N., longitude 111° 50' W., containing 53,531 inhabitants, and located 4,348 feet above sea-level. The city occupies an extensive area, is well built and attractive, with wide and well-shaded streets, and possesses an efficient sanitary system and excellent water works. The accommodations are good, there being several modern hotels. The soil is adobe. Irrigation is used, the water being carried in, ditches along the sides of the streets. " Salt Lake City," says Solly (" Medical Climatology "), " is one of the three Western cities of good size possible for the residence of those to whom a sunny climate is necessary and who desire to settle in an active business centre. The other two large cities are Denver, which shares with Salt Lake City the advantage of altitude, and Los Angeles, which is equally sunny but exposed to ocean influence." At the Salt Lake Hot Springs Sanatorium sulphur and salt baths can be taken ; and on the border of the lake, thirteen miles distant, reached by train, is the Salt Air Bathing Resort, well appointed, with nearly one thou- sand bathrooms. Here one can enjoy the strange ex- perience of bathing in water containing nineteen percent, of salt, and so buoyant that one can float in it with a Climate of Salt Lake Citt. Latitude, 40° 45' N. ; 111° 50' W. Elevation, 4,348 Feet. Pekiod of Observation, Ten to Sixteen Years. Temperature, Degrees Fahr.— Average monthly temperature Mean of warmest Mean of coldest Average daily range Highest or maximum Lowest or minimum Humidity- Average relative Precipitation— Average in inches Wind- Prevailing direction Average hourly velocity Weather— Average number of clear and fair days 29.0° 35.7 20.7 15.0 48.8 -6.1 61* 1.49 S. E. 4.07 19.8 49.0° 50.6 32.2 18.4 63.9 21.6 52* 1.74 S. E. 5.6 20.5 57.5° 69.3 47.3 22.0 83.3 35.6 45* 2.08 N. W. 6.2 23.7 75.4° 88.0 63.3 27.7 95.0 51.6 37* .53 N. W. 5.6 28.3 cb a S 64.3° 75.4 52.4 23.0 87.5 53.1 37* N. W. 5.4 27.3 6a 46.2 28.3 17.9 61.4 18.8 47* 1.40 N. W. 4.0 21.5 49.5° 59.5 39.6 19.9 72.9 28.9 49* 6.36 N. W. 6.0 64.4 71.5° 85.3 60.8 24.5 94.7 49.2 37* 2.16 N. W. 5.8 83.3 3 51.3° 60.9 39.0 21.9 74.9 30.0 N. W. 4.9 73.2 S a 31.9° 38.8 24.0 14.8 50.4 0.2 61* S. E. 4.1 56.3 51.3° 61.0 41.2 19.8 16.73 N. W. 5.3 277.2 16 REFERENCE HANDBOOK OP THE MEDICAL SCIENCES, sait^tor MUiVspr'gs. considerable portion or his body out of water. The lake is very shallow for a long distance from the shore, and it is a laborious task to wade to deep water. The tempera- ture of the water is comparatively high. Standart ("The Climate of the Great Salt Lake Basin," Transactions of the American Climatological Association, vol. vii., 1890) calls attention to the fact of the longevity of the inhabitants of this region, which he attributes to the influence of the climate ; and he narrates the inci- dent of a gathering of old folks representing three per cent, of the adult population of the great Salt Lake basin, where there were a thousand people who had attained the age of seventy years or over. Good hunting and fishing are to be had in the moun- tains and streams round about, and there are many short excursions to mountain resorts lying on the banks of at- tractive lakes. A few miles from the city, reached by an electric road, is Fort Douglas, a military post, from which is an extensive view. From the climatic table it will be seen that the tem- perature partakes of the characteristics of that of ele- vated regions. The diurnal range is large and it does not appear to be very cold in winter or excessively hot in summer. According to Solly, the average number of days above 90° F. is 30, and below 32°, 109. The average annual range as given by Standart is 93.5°. The aver- age relative humidity is very low and the rainfall small, indicating a very dry atmosphere. The prevailing wind is from the northwest, and the average hourly velocity 5. 3 miles for the year. The number of clear and fair days is 277, which means a large amount of sunshine. , Edward 0. Otis. SALT LAKE HOT SPRINGS— Salt Lake County, Utah. Post-Office. — Salt Lake City. Hotel and sanatorium. The springs are located in the northern outskirts of Salt Lake City. The water is conducted from thence to a sanatorium and bathing establishment in the heart of the city. This fine, commodious structure has a floor space of about fifty thousand square feet. The water, at a temperature of 112° F., is drawn from the springs through an eight-inch pipe, with a flow of about four hundred gallons per minute, and enters the establishment at a temperature of 110° F. Besides large separate swim- ming pools for men and women, there are twelve private pools and a number of elegant private bathrooms. A hotel and gymnasium are also connected with the enter- prise in the same building. According to an analysis by H. Hirsching, analytical chemist, in 1893, the water con- tains rather more than three hundred grains per United States gallon of solid ingredients. This is largely com- posed of chloride of sodium (about two hundred grains), but the water also contains appreciable quantities of the chlorides of calcium and magnesium, the sulphates of sodium, calcium, and magnesium, the carbonate of so- dium, and small amounts of several other compounds. It is also charged with sulphureted hydrogen in small quan- tities, as well as a considerable percentage of carbonic acid gas. The water is useful in the various ailments for which hot saline sulphur baths are prescribed. James K. Crook. SALTS, DISSOCIATION OR IONIZATION OF.- The. Appendix. -See SALT SULPHUR SPRINGS.^-Monroe County, West Virginia. Post-Office. — Salt Sulphur Springs. Hotels. Access. — Vift Chesapeake and Ohio Railroad to Fort Spring, where carriages meet visitors for springs. These well-known springs have been under the present management for many years, and have become justly es- teemed as one of the most charming and homelike of the Virginia Mountain resorts. The location is two thou- sand feet above the sea level, and is surrounded by the usual beautiful scenery and wholesome climate of the Alleghanies. The hotel buildings are chiefly of brick and Vol. VII.— 2 limestone. The largest, built of stone, contains seventy- two pleasant rooms, and has wide piazzas, two hundred feet long, overlooking the lawn. The parlor and great ball-room are also in this building. There are accommo- dations for three hundred guests. The springs are three in number, known as the " Old " or " Sweet " Spring, dis- covered in 1802; the "Salt Sulphur," discovered in 1805; and the " Iodine " Spring, known since 1821. We present analyses of the Old Spring and the Iodine Spring, the former by W. B. Rogers, the latter by D. Stewart: One United States Gallon Contains: Solids. Old Spring. Grains. Iodine Spring. Grains. l6!26 3.31 22! 36 84.90 18.31 9.24 2.00 10.80 33.00 7.00 2.33 24.00 68.00 20.00 Earthy phosphates, sodium chloride, cal- cium chloride, magnesium chloride, iron peroxide, alumina, silica, iodine. 7.35 150.28 172 .'48 Gases. Cubic inches. Cubic Inches. 13.28 3.44 34.56 19.12 These are valuable waters, containing as they do a large proportion of active mineral ingredients. Both contain a sufficient quantity of the purging sulphate to render them cathartic in their effects. The iodine spring contains a fair proportion of iron and appreciable quan- tities of iodine and bromine,- rare ingredients of sulphur waters. This water resembles those of Challes, in Savoy, and possesses alterative properties. It proves especially beneficial in scrofulous and syphilitic diseases. The waters of both of these springs are useful in abdominal engorgement, chronic constipation, chronic metallic poi- soning, functional hepatic disorders, rheumatism, gout, and scaly skin diseases. Cases of bronchial troubles and early phthisis also do well at this resort. James K. Crook. SALUBROL — tetra-bromo-methylene-di-antipyrin — is prepared by the action of bromine on methyl antipyrin. It is without odor, and is used as an antiseptic dusting- powder in place of iodoform. It is said to be a good haemostatic like antipyrin. W. A. Bastedo. SALUMIN, aluminum salicylate, Al 2 (C 6 H 4 OHCOO) 8 -(-3HjO, is a reddish-white powder, insoluble in water and alcohol, and soluble in alkalies. It is employed as an astringent dusting-powder in catarrhal conditions of the upper air passages. It is known as " salumin (insol- uble)." With ammonia it forms aluminum ammonio- salicylate, Al 2 (C 8 H 1 ONH 4 COO) !! + 2H 2 0, which is read- ily soluble in water and is used in the nose and throat as an astringent spray or gargle. This compound is called " salumin (soluble). " W. A. Bastedo. SALVATOR MINERAL SPRINGS.— Brown County, Wisconsin. Post-Ofpice. — Green Bay. This spring is the source of the Sal va tor Mineral Water. It does not appear to l)e used as a resort. An analysis by Professor Delafontaine, of Chicago, shows the fol- lowing mineral ingredients: One United States gallon contains (solids): Sodium chloride, gr. 1.60; sodium bi- carbonate, gr. 1.30; calcium bicarbonate, gr. 20; magne- sium bicarbonate, gr. 17.16; iron bicarbonate, gr. 1.30. Total, 41.80 grains. This analysis shows an excellent alkaline, diuretic, and mild laxative water, with ferruginous properties. It is 17 Sambucus. Sandarac. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. valuable in the treatment of acid dyspepsia, sluggishness of the portal circulation, Bright's disease, diabetes, and irritable states of the bladder and urinary passages. The water is entirely free from organic impurities, and is well adapted for table and club purposes. It has a large sale in different sections of the country. James K. Crook. SAMBUCUS.— Elder. "The flowers of Sambucus Canadensis L. (fam., Caprifoliacem)," U. S. P.. (but likely to be dropped from the next edition). This plant is a medium-sized or small shrub, with smooth, upright, rather simple stems, which are soft and herbaceous in the upper part. Their woody ring is very narrow ; their pith very large, and much used for holding small objects for microscopical section -cutting ; leaves opposite, peti- olate, pinnate, large; leaflets ovate-acuminate, serrate, rarely pinnate; flowers small, in large, compound, five- branched, flat-topped cymes, regular, pentamerous ; calyx minute ; corolla cream -colored, urn-shaped, with spread- ing lobes; stigmas three; ovary inferior, ripening to a purple-black, shining, spherical, juicy, berry-like drupe, containing three minute nutlets. The elder is a common plant in moist places over a large portion of this conti- characteristics. San Antonio (elevation 650 feet) is the chief city of this district, and is situated in Lat. 29° 27' North, about one hundred and thirty miles inland from the Gulf of Mexico. It has a population of over 50,000, composed of Mexicans, Germans, and Americans. The Mexican element presents many attractive and pictur- esque features, in the architecture, street life, and sug- gestions of bygone days in the old missions. The historic incidents connected with the life of the city also enhance the charm and fascination of the place ; for there is the famous Fort Alamo, the Thermopylae of Texas. The country is undulating, with no mountains nearer than thirty or forty miles, and the soil of the city is adobe. There is a pure water supply, and a more or less effective sewerage system. There are a number of hotels, boarding-houses, and restaurants, but the accommoda- tions for invalids are said to be doubtful. Probably the most satisfactory plan would be to keep house in one of the more eligible suburbs of the city. There are many opportunities for outdoor life, in horseback riding, driv- ing, etc. The climate is a mild winter one but uncom- fortably hot in summer, although the nights are com- paratively cool. Climate of San Antonio, Texas. Latitude, 29° 27' N. ; Longitude, 98° 28' W. Period Eight Years. January. May. July. Sep- tember. No- vember. De- cember. Tear. Temperature, Degrees Fahr.— Average or normal Average daily range Mean of warmest Mean of coldest Highest or maximum Lowest or minimum Humidity — Average mean relative Precipitation- Average in inches Wind- Prevailing direction Average hourly velocity in miles Weather- Average number of clear days Average number of fair days Average number clear and fair days Average number of cloudy days SI. 5" 19.8 62.8 43.0 81.0 16.0 65.6* 2.03 N. 7.5 10.3 9.0 19.3 11.6 61.9° 21.8 73.0 51.2 93.0 21.0 62.1* 1.42 S. E. 8.8 12.0 21.3 10.8 74.9° 19.6 85.2 65.6 97.0 47.0 2.85 S. E. 7.5 8.1 13.8 21.9 9.0 83.3° 22.1 95.3 73.2 106.0 66.0 64* .92 S. E. 7.5 13.8 14.8 28.6 2.2 77.5° 21.2 89.4 68.2 103.0 46.0 68.8* 2.84 E., S. E. 6.4 11 13 24 5 59.0° 21.1 71.6 50.5 88.0 32.0 65.3* 1.30 N., S. E. 7.4 12.1 10.3 22.4 6.5 54.9° 20.5 65.7 45.2 89.0 22.0 62.8* 1.82 N. 7.8 14.2 8.1 22.3 8.3 79.8 58.8 65-5* 25.27 8. E. 7.8 136.2 138.8 275.0 90.0 nent, and is represented by nearly related species in many other parts of the world. The flowers should be gathered in full bloom, and dried without heat. They then form a cream-colored or very pale j r ellow mass, which grows darker with time. They have a peculiar, rather agreeable odor, and a sweetish and slightly bitter taste. Their important constituent is volatile oil, with which occur resin, gum, wax, and sugar. The use of our elder was unquestionably derived from that of the black elder (8. nigra L.) of Europe, which is almost exactly like it in sensible properties. The Ameri- can has tufts of microscopic hairs in the forks of the branchlets of the inflorescence and in the sinuses of the calyx teeth, while the S. nigra has not. Elder is slightly aromatic, and when given in hot infusion is also diapho- retic. Its employment is confined almost entirely to household medication. The twenty -per-eent. infusion may be given ad libitum. The flowers are the least active portion of the plant. The fruits of this and related species, though used in pas- try and largely in wine-making, are laxative in the un- cooked state, and have been seen to intoxicate fowls. The young buds are powerfully cathartic or even emetic, as is the bark of the root. The leaves have been used for fly poison. The bark of the stem is a useful diuretic and hydragogue cathartic, emetic in over-doses. (See also Poisonous Plants.) Henry II. Busby. SAN ANTONIO, TEXAS.— The southwestern portion of Texas is regarded as the especial health-resort region of this State, and San Antonio, occupying a central posi- tion in this region, can be taken as illustrating its climatic From the meteorological table we see that while the winters are mild, nearly as warm as the autumn at New York City, the diurnal variation is large ; and also while the summer days are hot— many days above 90° F.— the nights, as has been said, are comparatively cool. The average annual rainfall for the eight years was 25.27 inches; and for twenty-one years, 30.6 inches (Solly, " Medical Climatology "). Occasional " northers " occur at San Antonio, but they do not last long. The average relative humidity is 65.5 per cent, for the year, which, considering the high temperature, means a moist atmos- phere. The average number of cloudy days during the year is 90; and the average number of clear and fair days, 275. Such a climate as this, while it is not an exceptionally excellent one in its various characteristics, yet affords an outdoor life in the winter in a mild and pure atmosphere. For the consumptive in good general condition, and with the disease not far advanced, and who, moreover is will- ing and able to " rough it " more or less, this region can be recommended. It does not, however, in the writer's opinion, possess the advantages of Southern California or of many resorts in the southern pine belt, either in the matter of climate or in that of accommodations. Almost every resort has its enthusiasts, and the following quota- tion from an article upon southwestern Texas by Dr T. K. Taylor in the Transactions of the American Clima- tological Association, 1888, may be said to have been written by one such. "For delicate children," Dr Tav- lor says, "who require the invigorating influences of moderately cool weather and active outdoor life that cli- mate is all one could wish during the winter season REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Sambucus. Sandarac. while the spring, with its multitude of flowers, its fra- grant breezes, its genial sunlight, and its evenings with their soft sweet repose, give one a better idea of an earthly paradise than any place we have ever seen, or hope to see in this broad land." San Antonio can be reached by three lines of railroad. Edward 0. Otis. SANATORIA (for treatment of tuberculosis). See Open-air Treatment, etc. SAN BERNABE SPRINGS.— Municipality of Dolores, Nuevo Leon, Mexico. These baths, known also as the Topo OMco, are situated 8 km. north of the city of Mon- terey, to which they are connected by a railroad. The water has a temperature of 105.8° F., and, according to an analysis by Gonzalez and Lambert, it contains the chlorides of sodium, calcium, and magnesium, the bicar- bonates of calcium and sodium, sulphate of calcium, silicate of alumina, silicate of lime, and sulphuric acid. The gases escaping from the spring are composed of car- bonic acid and nitrogen. A bathing establishment of considerable size has been constructed and is consider- ably resorted to, but as at most of the Mexican mineral spring resorts the accommodations are still very imper- fect and in sad need of proper development. In Monterey these baths enjoy a high reputation in the treatment of rheumatism, diseases of the skin, certain nervous affec- tions, and menstrual disorders. N. J. Ponce de Leon. SAN BERNARDINO HOT SPRINGS.— San Bernardino County, California. These springs are fourteen miles from Arrowhead Hot Springs. They are picturesquely located at an elevation of sixteen hundred feet above the sea level. The springs vary in temperature from 100° to 175° F. The waters have acquired considerable reputa- tion in the surrounding district. The following analysis was made by Prof. Oscar Loew : One United States gallon contains (solids) : Sodium chloride, gr. 7.46; sodium sul- phate, gr. 47.63; potassium sulphate, gr. 1.34; calcium carbonate, gr. 6.23; silica, gr. 11.95; magnesium, carbo- nate, and ferrous carbonate, traces. Total solids, 74.61 grains. It will be observed that the waters are saline and calcic. James K. Crook. SANDAL WOOD, OIL OF.— (Oleum Santali, U. S. P., B. P., P. G.) A volatile oil distilled from the heart- wood of Santalum album L. (fam. Santalacem). Sandal wood' is the product of a small tree of the East Indies. It has been highly valued from the most ancient times for the manufacture of objects which retain the fine fragrance of the wood for a very long time, and for use as incense. The trunk is small and its product is still further limited by the uselessness of the outer or sap wood. This is removed, either by trimming or by leaving it exposed to the action of termites, which find it agreeable and nutritious, while the oleiferous heart wood is highly offensive to them. To discriminate be- tween these two portions, the heart-wood is often known commercially as "pink" or "red "sandal wood. This custom leads, in turn, to some confusion between this and red saunders, which is also often called red sandal wood. Sandal wood occurs in small billets of a brownish-yel- low or reddish-yellow externally and of a more decidedly pinkish tinge internally. It is very hard and heavy, and of a tough and splintery fracture, and emits, especially when heated, the characteristic odor of the oil. The tree, on account of its very extensive collection and the careless methods employed, was long ago placed under government protection and is now cultivated upon a great scale. The distillation of the oil has also been carried on under government supervision, with the express object of preventing adulteration. In spite, however, of all precautions, such great difficulties have been encountered in securing a pure article of native dis- tillation that many firms prefer to incur the heavy ex- pense of importing the wood and distilling it here or in Europe. The yield of oil from a wood of first quality is said to be about five per cent. The wood itself finds no employment in medicine. The oil is thus described in the Pharmacopoeia : A pale yellowish or yellow, somewhat thickish liquid, having a peculiar, strongly aromatic odor, and a pungent spicy taste. Specific gravity: 0.970 to 0.978 at 15." C. (59° F.). It deviates polarized light to the left (distinction from Australian Sandal wood oil [specific gravity 0.953] and West Indian [specific gravity 0.965] sandal wood oil, which deviate polarized light to the right). Readily soluble in alcohol, the solution being slightly acid to litmus paper. If to 1 c.c. of the oil, at 20° C. (68° F.), there be added 10 c. c. of a mixture of three volumes of alcohol and one volume of water, a perfectly clear solution should be obtained (test for cedarwood oil, castor oil, and other fatty oils, etc.). Oil of sandalwood belongs to that class of volatile oils commonly denominated "terebinthinate." Like copaiba, which it resembles in many respects, it is often called a balsam, though the term is very incorrect, neither ben- zoic nor cinnamic acid being contained. It is said to consist almost wholly of the alcohol CisH^oO and the aldehyde CsH^O. Action and Use. — The absorption and elimination of this oil are rapid, the latter occurring chiefly through the kidneys and the lungs, so that it might be classed as a stimulating and disinfectant diuretic and expectorant, with some astringent properties also. Its administration is frequently followed by discomfort in the stomach and dryness of the throat, and occasionally by vomiting and colic. Disagreeable eructations and its taste are complained of by some patients, but on the whole it is less unpleas- ant than copaiba. Its elimination by the kidneys, which is sometimes accompanied by a feeling of tension there, changes the odor of the urine, and causes it to become cloudy with acid, in the same way as copaiba does ; al- cohol, by clearing up this cloudiness, which is caused by a resinous precipitate, will distinguish it from albumen. The sandal-wood products in the urine exert upon vesi- cal, and especially gonorrhoeal, inflammations a beneficial action very similar to that exerted by copaiba or cubebs. Sandal-wood therefore is frequently employed as an ele- gant substitute for these drugs. Reports differ widely as to the relative value, as antiblennorrhagics, of copaiba and sandal- wood oils, but the preponderance of evidence appears to be in favor of the former. Sandal-wood oil is especially serviceable in recent acute cases, with con- siderable discharge. The oil is frequently given dropped upon sugar or shaken up with mucilage, but is far more largely taken enclosed in gelatin capsules, either pure or mixed with copaiba or cubebs. The dose is five to twenty minims four or five times a day, and its administration should be continued for a week or so after the symptoms have dis- appeared. Allied Pbo.ducts. — Eight or nine species of Santalum are known, all natives of the East Indies. Various at- tempts have been made to utilize the products of several of these species, as well as somewhat similar products, though not of this genus, from the West Indies and South America ; but none of them possesses the fine odor or other characteristics of the genuine, and it is doubt- ful if they now find their way into commerce. Henry H. Busby. ShTiDARkC.—Sandaraca. Resina Sandaraca. Aresin obtained in northern Africa from Callitris quadrivalvis Vent. (Thuja articvlata Shaw. — Fam. Pinacece or Oonif- erce), a small evergreen tree not distantly related to the cypress. The resin exudes spontaneously from the trunk and branches, and dries in tears resembling in form short, broad, blunt, simple or compound icicles, and rarely ex- ceeding or even reaching an inch in length. They are 19 San Diego and Lit- toral California. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. dull on the surface and covered by a whitish powder produced by attrition, of a glassy fracture and transpar- ent within. Occasionally insects are found embedded in them. Upon being chewed, the tears crumble to a line powder which refuses to become plastic, whereas mas- tiche, which also occurs in small yellowish, though rounded tears, readily softens into a plastic mass. Pow- dered sandarac, which is non-adhesive and white, with a pleasant resinous odor and a resinous and bitter taste, is called "pounce," and was formerly used to rub over the surface of paper where an erasure had been made, to pre- vent the ink from running when it was written over again. Either alcohol or ether will dissolve sandarac completely, while turpentine, chloroform, or carbon bi- sulphide only partly dissolves it. The volatile oil of sandarac exists in very small amount, as does the unstudied bitter principle. The resin consists almost wholly of sandaracolic and callitrolic acids, about ten per cent, of the latter and between eighty and ninety per cent, of the former. Sandarac is not used at present in medicine. Henry H. Busby. SAN DIEGO AND LITTORAL CALIFORNIA.— In a consideration of littoral California we select San Diego because there are few places in the United States with a more complete climatic record; it has an uninterrupted temperature and rainfall record extending back for over half a century. This station was also among the first to be equipped with self-recording apparatus, and it has a continuous automatic record of temperature, rainfall, wind ve- locity, wind direc- tion, and sunshine for each moment of time, thus giv- ing data that are absolutely reliable. It is on account of my familiarity with the ex- cellent records of this station that San Diego * and Coronado are selected * as the type in this paper, but the statements and de- ductions apply almost equal- ly to the coast of Southern California. We must study a wide ex- panse of country when we are considering the climatic peculiari- ties of the coast of this region, as the coast has a marked influence on the interior, and it in its turn mark edly influences the coast; indeed, fur- ther than this, the vast Calif ornian coast line presents three distinct climates, while on the great inland plain there is a fourth type of climate. To quote from my re- cent paper before the American Climato- ®t.'^» logical Association (Philadelphia Medical Journal, October 11th and 18th, 1903), we sha barely mention the northern climatic belt, the centre of which is at the junction of the moun- tain chains near the northern border of Califor- nia, and which embraces also the country known as Oregon, Washington, British Columbia, and the coast of Alaska and its islands. The central clima- tic subdivision extends from a point below this nor- thern junction of the mountains to Point Conception on the coast. It is about here that the mountain chains, by their junction, establish a transverse line of separation, thus warranting us in describing a Northern and a Southern California, each with its dis- tinct topography and its very distinct climatic condi- tions. Southern California, then, embraces, so far as a study of its climate is concerned, all that part of the State which lies below the transverse high mountains about Point Conception. It is with this strip of coast that we are alone concerned, from Point Conception to Coronado. At Point Conception the coast line changes its general direction and runs nearly east, the mountains run east- ward for a sufficient distance to protect the country from the north; but afterward they again turn south, thus once more protecting the coast from the desert, which is east of it. The arrangement of the mountains and the trend of the coast are the keynote of the delightful climate of littoral California. The Alaskan current is separated from the land by the curve in the coast, and the Kurosiwo, or great Japan current, leaves the land at Point Conception and never returns. This separation is materially assisted by the coast islands which are located between San Mig- uel and the Coronado Islands and by those lying farther south, off the coast of lower California, the Baja Cali- fornia of the Mexicans. To understand fully the factors that make the coast climate so pleasant we must consider the formation of the country contiguous to the coast. The general topog- raphy of California, more marked in the north, is a double mountain range parallel with the long axis of the State, with large fertile plains and valleys, with enor- mous watersheds included between them. In the south this general plan is somewhat modified. While the east- ern range, the Sierras, serve as a wall to protect the coun- try from the great arid desert plains, the coast range is much lower and no longer shuts out the sea; indeed, at some points the whole interior is quite open to the sea, so that the Santa Clara valley, the valley of the San Buenaventura River, the San Fernando Valley, the San Gabriel Valley, the valley of the Santa Ana River, the San Jacinto River, the Los Angeles River and plains, and the San Diego country constitute a great open coast land backed and protected by the high Sierras. A new- comer from the eastern country will be somewhat surprised at the designation of plains as applied to these valleys, and he will also be somewhat dis- appointed at their size. The first effect will probably be one of smallness and narrowness as compared with the homeland valleys, but their size is greatly increased by the hilly uplands into which they insensi- bly merge. This is most noticeable in the great upland plain of San Jacinto, south toward Coronado and San Diego. As Lindley and Widne}' say : " The Sierra, which north of the Mojave Desert makes a great curve westward around the sound end of the San Joaquin plain of the central belt, turns south- ward again oppo- site Santa Barbara and Ventura coun- ties, and doubling back upon its course walls in the west end of the des- ert, then turning di- rectly eastward, separates the des- ert from the Los Angeles and San Bernardino plains. Turning southward again, it stands as Fir,. 4141. -Map in Relief of the Topography of Cali- fornia. A comparison of this map with the tem- perature and rainfall charts of the State, will show how this topography exerts an influence upon the climateof California. (From California Sei'tion, Annual Summary, 1900, of Climate and Crop Ser- vice of the Weather Bureau, liv Alexander G. MeAdie.) 20 REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. San Diego and Lit- toral California. a wall between the Colorado desert and that portion of Southern California lying west of its base." The range varies in height from five thousand to seven thousand feet. > Unlike the northern and central portions of the chain, the range breaks down in the south at several points into low passes between the coast and the interior. " The pass, by which the Central Pacific crosses the Sierra, is 7,017 feet in elevation. Yet the Soledad Pass, by which the Southern Pacific crosses the Sierra in Southern Cali- fornia, is only 2,822 feet. The Cajon Pass, by which the Santa Fe enters, is of about the same height. There are numerous other comparatively low passes through the Sierras at the west end of the Mojave Desert, leading toward the sea in Ventura and Santa Barbara counties, and also through the range south of San Gorgonio. These passes through the Southern Sierra have a marked influence not only upon the climate of the coast portion of Southern California but also upon that of the deserts lying at the base of the Sierra. " The accompanying map in relief, prepared by Alex- ander G. McAdie for the California Section of the Climate and Crop Service of the Weather Bureau, 1901, if com- pared with the statements made above and with the tem- perature and rainfall charts of the State, will afford a graphic illustration of the influence of the diversified topography of California v, pon its climate. *As I have said elsewhere, a great deal that is mislead- ing has been written about the climate of Southern Cali- fornia. Its charms have been exaggerated and its draw- backs have either been passed over in silence or have been painted in glowing and attractive colors. The simple truth is quite good enough. It is a fact that in California of the South is to be found the best yearly climate in the world. Other localities have as good or perhaps a better climate than ours at their best, but certainly none of them has been blessed with this happy condition the year round as we have been on the coast. A striking peculiarity, and one leading to much confu- sion, is the great diversity of climate in this country and the different climatic conditions which may be encoun- tered in even a single day's journey. At the lower stations the various climates have the * " Two Health Seekers, in Southern California,' raden. J. B. Lippincott Company, Philadelphia. Edwards and Har- CLIMATOLOGY OP SAN DIEGO, CALIFORNIA. By Ford A. Carpenter, Observer, Weather Bureau. Monthly Mean Temperatures (Degrees Fahr.) for a Period of Ten Years (1892-1901). Tear. January. February. March. April. May. June. ! July. August. Sep- tember. October. No- vember. De- cember. Annual. 1892 . . . 1893 1894 1895 1896 1897, 1898 1899 1900 1901, Mean.. 55.1 57.4 49.5 53.2 55.5 55.8 50.8 55.5 57.8 56.2 54.7 55.0 54.4 50.5 55.5 57.7 54.7 55.2 53.4 57.6 57.5 55.1 56.0 54.2 52.6 55.4 58.2 54.2 54.5 56.4 59.2 60.0 56.1 57.8 57.5 56.4 57.8 56.5 59.8 59.1 58.2 56.8 57.4 57.7 61.0 61.0 58.6 61.9 62.0 60.9 58.8 57.7 60.9 60.0 60.3 62.0 63.4 61.4 65.0 64.8 63.4 63.8 61.4 64.4 62.5 63.2 64.9 67.4 64.8 65.6 68.6 67.0 66.7 65.6 67.6 65.6 66.4 67.8 70.0 67.0 61.7 69.4 69.9 70.6 65.8 66.2 68.2 67.7 65.4 64.6 65.9 67.4 66.7 68.1 68.5 65.5 65.6 64.8 66.3 62.7 62.7 62.8 64.4 64.2 62.4 62.3 62.7 63.1 62.8 63.0 60.9 57.6 57.1 59.4 59.7 60.2 59.4 60.8 64.6 60.8 60.0 54.2 57.4 54.8 55.0 59.0 55 56.6 58.7 60.4 57.8 56.9 60.2 60.6 58.4 60.5 61.9 61.0 60.5 60.1 62.0 61.2 60.6 Monthly, Seasonal, and Annual Precipitation at San Diego, California (1892-1901.) Tear. s i >-3 ■ >. 0v 03 4 1 ft CO a i 3 1o s A. 8 * 02 a -1-3 I o O = •2 pa s eg 3 a a •< §1 a) ° m es a o S3 03 1892 1.58 2.96 0.96 0.41 1.15 0.13 0.00 0.05 T. 0.22 0.94 0.69 9.09 1891-92 8.65 1893 .78 .47 5.50 .22 .39 T. T. .00 .00 .11 .91 1.91 10.29 1892-93 9.21 1894 .29 .49 1.05 .11 .09 .01 .00 .04 .01 T. .00 2.26 4.35 1883-94 5.01 1895 7.33 .53 1.43 .11 .19 .00 .00 .00 .01 .27 1.19 .27 11.33 1894-95 .11.86 1896 1.27 .02 2.89 .25 .03 .01 T. .13 T. .97 .98 2.18 8.73 1895-96 6.34 1897........ 3.13 2.72 1.53 .02 .12 T. .01 T. T. 1.06 .02 .32 8.93 1896-97 11.66 1898 1.71 .06 .91 .22 .66 .02 .00 .00 .07 .00 .15 .87 4.67 1897-98 4.98 1899 2.34 .30 .85 .29 .10 .27 .00 .07 .00 .35 .86 .65 6.08 1898-99 5.31 1900 .69 .03 .53 1.26 1.45 .08 .00 T. T. .30 1.43 .00 5.77 1899-00 5.90 1901 2.08 4.77 1.07 .01 .77 .02 T. T. .06 .28 .41 .02 9.49 1900-01 10.45 General average 2.12 1.23 1.67 .29 .49 .08 .00 .04 .03 .46 .69 .92 7.87 7.93 Maximum and Minimum Temperatures (Degrees Fahr.) for a Period of Ten Years. January. February. MARCH.' April. MAY. June. July. August. September. October. NOVEMBER. December. Tear. m a i A i d i a s a i a i a i a >< 08 a i a 03 a « 1 a B B a a 76 B 41 s 77 B 44 B 67 B 53 B 78 B 53 B B B B B B B 84 B 50 B B a 1891 76 35 70' 34 88 58 85 60 89 55 82 44 72 32 1892 75 38 68 42 78 44 80 41 87 47 75 51 75 57 80 57 80 54 83 46 84 40 71 SK 1893 80 38 75 40 75 40 78 43 88 49 75 53 79 57 81 59 77 53 88 50 83 40 82 38 1894 69 32 69 34 72 36 83 43 72 45 73 50 77 57 90 55 90 52 87 45 78 45 70 41 1895 77 36 82 39 74 38 81 44 8(1 51 77 51 74 57 78 54 90 54 84 54 85 38 79 34 1896 77 39 83 . 39 85 41 74 42 98 48 89 54 80 56 88 59 80 54 79 52 76 43 76 46 1897 73 40 76 38 70 40 88 46 67 50 70 54 79 59 89 60 83 58 76 51 83 45 80 36 1898 78 •«i 75 42 77 38 86 45 69 51 88 54 77 60 83 63 91 56 81 51 76 43 79 43 1899 74 *i 76 34 8« 44 93 46 66 48 7(1 55 78 57 76 58 92 55 93 48 81 50 80 46 1900 79 46 76 45 80 46 67 45 75 49 87 5B 84 60 8(1 59 87 53 72 50 89 51 79 44 1901 75 40 83 44 82 47 66 46 67 51 86 53 74 57 79 58 72 56 96 51 80 49 76 35 21 Sau Die^o'de fo a s K ° 8 ' REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. Temperature and Weather Summaries for a Period op Fifty-Two Years. p a •-3 i 03 p. < 5? s a p •-3 P p M P < .o s u O u = ■2 > »-2 S3 P P a Temperature, Degrees Fabr. Highest monthly mean and 57.8 1900 49.5 1895 81 4, 3902 33 *3l\'i880 35 16.9 2.4 65.7 40.2 17 7 7 6 58.5 1886 50.5 1894 85 12, 1889 34 in-ii-'94 37 13.7 2.1 69.2 41.9 14 9 5 8 60.0 1901 52.1 1880 99 27, 1879 38 6,1880 14, 1898 43 14.2 2.3 71.3 44.3 11 10 10 7 63.8 1861 56 1872 93 12,1880 39 7,' 1875 40 14.2 2.2 74.3 50.5 13 10 7 4 65.7 1861 57.7 1899 98 25,1896 39 7,' 1875 36 ■ 12.2 1.6 72.1 52.6 9 11 11 3 69.1 1857-67 61.4 1894-99 94 10, 1877 50 14,1884 13, 1894 35 12.1 1.6 75.8 55.4 8 13 9 1 73.2 1852 63.4 1880 88 25, 1891 54 16,'i894 22 11.6 1.7 78 59.5 14 11 6 75.1 1864 65.8 1880-99 92 15,1884 54 29,'i879 28 11.4 1.7 81.1 60.8 12 15 4 73.6 1852 63.1 1880 101 22,1883 50 18,'i882 35 13 2 82.9 57 16 11 3 68.8 1853 59.7 1886 96 21, 1901 44 30,'i878 37 14.1 1.8 79 49.8 18 10 3 2 64.6 1900 56 1886 91 4,1890 38 8,1881 24, 1895 34 17.7 2.3 75.6 44.9 19 9 2 3 63.3 1867 50 1856 82 6, 1874 32 25,' 1879 40 16.2 1.9 75.6 42.8 17 10 4 5 63.8 1867 Lowest monthly mean and 58.4 1894 Absolute maximum and 101 9-22-1883 Absolute minimum and 32 1-31-1880 Greatest daily range 12-25-1897 43 13.9 2 Mean of three consecutive 82.9 Mean of three consecutive 40.2 Weather- Average number of clear 178 Average number of partly 116 Average number of cloudy 71 Average number of rainy 39 *Also 21st, 1883: 7th. 1894. peculiar charm of California's equability — an equability that is most remarkable. In San Diego, from 1875 to 1901 — a total of 9,861 days, there were 9,545 days on which the temperature did not rise above 80° nor fall below 40" F. Newcomers are often bewildered by the many varie- ties of climate, and make statements to far-away friends that add chaos to confusion in the minds of Eastern people. One traveller reports California all sunshine and flowers, another all fog and cold. Some complain of the dry desert winds with their exciting electrical conditions, while others dwell upon the excessive humid- ity ; when the probable truth is that the critic has not selected the proper environment and has passed by what he is seeking, which is no doubt within a few short miles of the spot where he may happen to be. There is little seasonal change in the extreme southern part of the State. I am accustomed to say to inquirers that our winters resemble September and October in the middle Atlantic States and that our summers are like April and May in the same region. The dividing line between summer and winter is more imaginary than real. The greatest change in the temperature occurs at night, being more marked in the interior than on the coast. I wish to call particular attention to the apparent difference between sunshine and shade and midday and midnight. This change is more a subjective sensation than a reality and is true of all semitropical localities. It is less marked in California than in Italy, but it always appeals strongly to the newcomer, who is surprised at the imme- diate sense of chill which he experiences when he en- ters the shade from the direct rays of the sun. As the night advances the temperature decreases, and while this change may not cause the mercury to fall many degrees, still it is very noticeable to the individual. This is less marked on the coast in summer and more so at all seasons of the year in the interior. The days are characterized by a constant sea breeze which blows with astonishing regularity ; it is rarely too warm for comfort, as is often the case at Cape May, Atlantic City, Long Branch, or other popular Atlantic coast resorts. Several times dur- ing the year the so-called desert spells occur. This is when the land breeze or wind from the desert, many miles in the interior, gains ascendency over the prevailing west- ern or ocean breeze. During this time the thermometer is apt to show a very high registration. Under these con- ditions I have seen it at San Diego register 98° F., but for only a few hours. These hot winds may last two or three days. The nights at this time are always cool and pleasant. These are the only evenings on the coast upon which one may sit out of doors with comfort and with- out chill. Bainfall. — Each rainy season has its own peculiarities. It may be one of constantly recurring rains, or the rains may be light, interspersed with long periods of almost constant sunshine. Hence the records do not help us much to predict for future rain probabilities. It is not altogether unusual to have a very deficient rainfall. Thus, for example, San Diego, with a normal rainfall of about ten inches, has had in the last fifty -two years a minimum of 3.02 and a maximum of 27.59 inches. Fog. — The coast fog, about which so much has been written, is most frequent during the months of April, May, and June. The fog appears about nightfall and dis- appears after sunrise ; by nine o'clock the coast is usually free from fog. Some days during the months mentioned are foggy until half-past twelve or one o'clock. The records show that Coronado and San Diego have nearly three hundred days a year that are recorded as clear. The East has its cloudy weather in the winter ; we have ours in the summer. Again, the maximum sunshine in Southern California is in the winter time, in the East during the summer. Monthly Relative Humidity (Per Cent.) for a Period of Thirty-One Years. Kecord Began January 1st, 1871. >> &% a 3 i a; — — i OB .55 a a k as s a p < H O •AS -3 s A.M 72.9 77.6 81.2 82.2 82.5 84.3 85.9 85 4 84 7 81 3 78 4 75 P.M 73.U 73.5 73.9 73.4 74.8 75.9 76.4 76.4 78.0 76.2 72.8 72.9 Average 73.4 75.6 77.6 77.8 78.6 80.5 81.2 80.9 81.4 78.8 72.6 72.9 Humidity. — Carpenter, the weather " observer at San Diego, very aptly remarks that the oft-repeated state- ment, "driest marine climate," as applied to San Diego, is not sufficiently explained. Why is our humidity so much less than that of Seattle or Santa Barbara, for example? We find the explanation in these two cir- cumstances; distance from the average storm track and nearness to the desert. Our humidity is as constant as our temperature, and plays a very important part in the excellence of the climate. So long as the temperature is 22 REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. San Diego. [Banog. San Diego de los between 55° and 65° F. (and that is about half the time), the humidity is always seventy per cent. Whenever the temperature increases, the amount of moisture naturally decreases, for the capacity of the air for holding the vapor is correspondingly decreased. Strange as it may seem, this is also true of the other extreme in tempera- ture in this desert-sea climate ; the winter cold is a dry cold, just as the summer heat is a dry heat. A general knowledge of the climate of Southern Cali- fornia is obtained, says Solly, if we remember that the coast is cool and moist and the interior hot and dry ; " it should be thoroughly understood by the Eastern visitor, in his search for health, that if he seeks more days of sunshine and opportunities for outdoor life, with a more equable temperature and an average humidity a little greater than that of New York or Boston, he can find what he wants at Santa Barbara or San Diego " (or Coro- nado). The same writer adds that to those to whom the presence of dry air is not important, California offers many attractions from Monterey to Coronado, and he concludes that it can be said that the coast climate is delightful, equable, and healthful. Wind. — The wind movement is moderate, the yearly average is about 5.6 miles an hour. During the day the wind blows from nearly every point of the compass. The coast clearly shows the phenomenon of land and. sea breezes, for the air, warmed by the earth, rises and creates a draught from the cooler sea, so that by about nine o'clock the breeze commences and increases until about 2 p.m., at which hour it blows at about the average rate of twelve miles an hour. At or about sunset this west- erly wind dies down, the land cools, and a current of air starts toward the warmer sea. William A. Edwards. SAN DIEGO DE LOS BANOS.— The best-known and most-employed mineral springs of those abounding in Cuba are the springs situated in the town called San Diego de los Banos, in Pinar del Rio. This town is situated about ninety miles from the city of Havana and may be reached by railroad as far as Paso Real and thence by stages or carriages. This part of Cuba is not only one of the most picturesque on the island, but it is also the best known, for San Diego is surrounded by those tobacco estates which have made the name of Cuba so well known where- ever the luxury of a good cigar is appreciated. These springs have been known for over a century, tradition attributing their original discovery to an old negro, a runaway slave, who is said to have been cured of leprosy by bathing in these waters. During the lust thirty years these springs have not enjoyed the vogue that they formerly had, but this has been due to the difficulties of transportation and to the disturbed politi- cal condition of the country. However, now that the island is at peace, there is no doubt that the springs of San Diego will develop with the rest of the country. The population of San Diego during the closed season is about 1,500, and this increases to five times that num- ber during the bathing period, which begins in the latter part of January and includes February and March. The temperature the year round fluctuates between 80° and 87° F. The River San Diego during the rainy season becomes a raging torrent, and in 1899 it swept away all the buildings connected with the bathing establishment. Only three of the springs have thus far been utilized. One of these issues from the river-bed itself, the others are situated on the shore ; the waters of the first have been isolated from the general body of the stream by means of dams and retaining walls. The establishment at San Diego consists of three pools or tanks and twelve tubs with their corresponding buildings, such as dressing and waiting rooms for all the departments. The Templado Spring. — This bath has, for women, a de- partment measuring 8 metres long by 7 wide; it is lined with vitrified tiles and is furnished with a wooden floor. The tank on the men's side is larger and more comforta- ble; the pool has a depth of more than three. feet and its temperature is constantly at 34° C. This is the larg- est and most important of the springs; it yields 860,000 litres in the twenty-four hours. The next most important spring, from the point of view of the volume it yields and the curative properties of its water, is the Tigre. This pool is 8 metres in diam- eter, enclosed on all sides, thus allowing a concentration over the water of vapor and sulphurous acid gas. This has led people to believe that it is the stronger of the two baths, but experiments have proved that the two springs are really one and that the Tigre and the Templado are merely different outlets of the same spring. Years ago this pool was reserved for colored people. The third spring, called the Paila, is certainly the most picturesque. The water issuing from the bed of the river itself reaches it after an admixture of fresh water from the river and the water from about thirty smaller springs. All these waters together collect into a pool about two hundred feet wide and in some places six- teen feet deep, thus allowing the bathers who are so in- clined to add the exercise of swimming to the other at- tractions. From the above it can easily be understood that the temperature and strength of the water of this pool are subject to constant changes. In connection with this pool there is a dressing and waiting room 20 metres long by 6 metres wide, from which steps lead down to the baths. The chemical analysis of these waters was made twenty- eight years ago by the brothers Aenlle. Since that time, however, there have been several earthquakes of more or less severity and the composition of the waters may have varied to a slight extent. According to the analysis above mentioned one litre of the Templado or Tigre has the following composition: Hydrosulphuric acid, 0.152; sulphate of lime, 0.136; sul- phide of calcium, 0.838; chloride of sodium, 0.032; bicar- bonate of magnesium, 0.080; alumina, 0.006. Totalsolids 1.244 gram. Carbonic acid gas is present in slight amount. Silicic acid, carbonate of iron, nitrogen, oxygen, or- ganic matter, undetermined. Density, 1.014. The color of this water is bluish at the spring and in the bath, outside it is colorless and as clear as drinking- water. The odor is characteristic of hydrosulphuric acid. The taste is sulphurous and the temperature is 34° C. (93.2° F). The Templado spring yields 860,000 litres of water in the twenty-four hours, while the Tigre yields 240,000 during the same time. The analysis of the Paila spring gives the following result per litre: Sulphide of calcium, 0.218; sulphate of lime, 0.850; sodium chloride, 0.022; bicarbonate of mag- nesia, 0.120; alumina, 10.012. Total solids, 1.222 gm. Carbonic acid gas is present in a small amount. Undetermined quantities : Sulphurous acid, silica, car- bonate of iron, nitrogen, and organic matter. The temperature of this spring varies from 22° to 25° C. According to Dr. Cabarrony, medical director of the establishment, the physiological effects of these waters are as follows : " They stimulate or deaden the appetite according to individual idiosyncrasy, and act as a stimu- lant on the circulatory and nervous systems. The rapid- ity of the pulse is increased. They may cause headache, insomnia, and a general stimulating of the capillary cir- culation. Sometimes tachycardia of a transient nature is observed. " On the respiratory apparatus the effect of the water is frequently at first to cause coryza, pharyngitis, and bronchitis, which rapidly subside. Upon the kidneys it seems to act as a stimulant, causing increased secretion of urine and a noticeably greater elimination of uric acid. It also stimulates the sexual organs. Like all waters of this nature it also stimulates the functions of the skin." According to the same authority the use of these waters is beneficial in such diatheses as the herpetic, rheumatic, and scrofulous, especially so in the first two, in which the effect seems to be immediate. It is also of service in syphilitic affections. 23 San Francisco. San Rerno. REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. By far the largest number of patients who visit San Diego are sufferers from rheumatism, and extraordi- nary results in the treatment of this disease are said to be obtained by the use of these warm baths._ They are of great benefit in all the visceral manifestations of the disease, in endocarditis, pericarditis, cerebral rheuma- tism, sciatica, neuritis, chorea, etc. iV. J. Ponce de Leon. SAN FRANCISCO, CALIFORNIA.— The metropolis of the Pacific coast is situated upon the northern end of a peninsula, in latitude 37° 47' N. and longitude 122° 23' W. On the west, north, and east the city is surrounded by water. The Pacific Ocean washes the extreme west- ern side of the city, a fine ocean driveway extending from the Cliff House to the overflow basin of Lake Merced. The Golden Gate (the name was applied by General Fremont while looking westward from what is now Oakland) is a water passage about a mile wide, con- necting the Pacific Ocean and the Bay of San Francisco. The harbor is generally conceded to be one of the beau- tiful harbors of the world. The bay extends twenty-five miles north and forty miles south of the city. There are numerous islands in the bay, and on some of these, as, for example, Belvedere, business men of San Francisco have elaborate summer homes. The coves and lagoons are favorite anchorages for house boats or arks. The city of San Francisco has many hills, among the more prominent of which are Telegraph Hill, Russian Hill, Nob Hill, and Rincon Hill. In 1850 the city was nothing more than sand dunes and sand hills ; and even at the present time in the extreme western end of the city these shifting sand stretches can still be seen. The cli- mate is peculiar ; the reasons for which are to follow. The winds are somewhat too rigorous for invalids, but for healthy people they are very stimulating. Overcoats and heavy wraps are worn in midsummer as well as in winter. Indeed heavy underclothing can be comfortably worn every day in the year. age velocity of twenty miles per hour. From May until September little if any rain falls, and no matter how overcast or threatening the morning may seem, within a few hours, generally before ten o'clock, there is bright sunshine. Great banks of low fog roll in through the Golden Gate on summer afternoons. There is probably no other part of the Pacific coast where such a strange mixture of marine and continental climates can be found. The topography is so remarkable that marked climatic contrasts occur within short distances. Thus at any of the ferries one may see sealskin coats and white duck garments together, because the traveller needs warm garments crossing the bay and in the city ; while at Sau- salito, San Rafael, San Mateo, or any of the suburbs, summer clothing is necessary. It must be remembered that the great Sacramento-San Joaquin Valley, a basin five hundred miles in a uorth-and-south direction and fifty miles wide, lies due east of San Francisco, and that on summer afternoons there is often a difference of 55° F. in temperature in a distance of fifty miles. Owing to the proximity of the Pacific the temperature in San Francisco is very equable. A native of San Fran- cisco cannot say off-hand which is the warmest and which the coldest month of the year; because the range is very small. The mean annual temperature determined from the records of thirty -two years is 56.1° F. May and November have practically the same temperature. The mean temperature for July is 58.7° and for Decem- ber 51.5° F. The highest temperature ever recorded was 100° and the lowest 29° F. Abnormally warm and cold periods last as a rule about three days. The mean for the three consecutive warmest days at San Francisco has never exceeded 76.3°; and of the three consecutive cold- est days the mean temperature was not below 40.7°. The mean daily range of temperature is 12°. The sunshine is less in San Francisco than at localities a few miles away, which is due to the prevalence of fog. The city is considered a very healthy one because it is washed by water and well ventilated by the strong winds. Latitude, 37° 47'; Longitude, 122° Thirteen Years, 1891-1902. 23' W. Period op Observation Climate of San Francisco, Cal Furnished by permission of Chief of Weather Bureau, Prof. Willis L. Moore. Temperature, Degrees Fahr.— Average or normal Average daily range Mean of warmest Mean of coldest Highest or maximum Lowest or minimum Humidity- Average relative. Precipitation- Average in inches Wind- Prevailing direction Average hourly velocity in miles Weather- Average number of clear days Average number of fair days. Average number of clear and fair days i 3 a 03 •-3 ■ >-■ 1 a < 03 H a 3 t-3 t-3 1 3 §■■2 go a a? a> .a o O . &i oo 158 > PS 8 50.1° 52.2° 53.7° 54.9° 56.7° 58.7° 58.7° 59.8° 60.8° 59.9° 56.4° 51.5° 10.0 11.0 11.5 13.0 11.0 14.0 13.0 11.0 13.0 13.0 11.0 10.0 59.3 62.5 62.7 65.1 64.8 68.5 66.2 69.3 71.3 69.0 67.2 57.7 41.7 43.5 43.9 45.6 46.9 49.2 49.3 50.9 51.3 51.2 47.7 43.8 78.0 75.0 80.0 87.0 91.0 100.0 90.0 92.0 94.0 94.0 83.0 72.0 36.0 34.0 33.0 40.0 43.0 47.0 47.0 47.0 47.0 47.0 38.0 37.0 79* 78* 78* 78* 79* 80* !84* 86* 83* 80* 76* 80* 4.85 3.54 3.14 1.81 .73 .14 .02 .02 .33 1.05 2.75 4.80 N. W. W. W. W. S. W. S. W. S. W. W. W. W. N. 7.0 7.6 8.8 10.4 11.3 13.0 13.1 12.3 10.1 7.8 6.6 7.0 11 12 14 15 12 21 18 15 15 17 13 12 10 8 11 8 13 7 10 14 11 8 8 8 21 20 25 23 34 28 28 29 26 25 20 20 56.1° 12.0 100.0 *33.0 + 22.74 W. 8.7 * The lowest official temperature recorded In San Francisco was 39° on January 15th, 1888, preceding above record. + The rainfall has been recorded with great detail for fifty- three years. The climate is a moist one, the mean relative humidity exceeding eighty per cent. During the morning hours, especially in summer, the sidewalks look as if a light shower had prevailed, but in reality the dampness is due to condensation of fog. The prevailing direction of the wind is from the northwest, and on summer afternoons the wind blows with great regularity. Between the hours of 1 and 7 p.m. the wind is from the west, with an aver- It is worth noting that children escape the disorders inci- dent to hot weather in Eastern cities. Women and chil- dren have as a rule ruddy complexions, bright eyes, and a good carriage. Natives of San Francisco are in gen- eral large and well-formed. The climate is, however, too moist for those affected with renal, rheumatic, and pulmonary troubles. The summer climate is bracing and acts as a tonic in cases requiring such treatment. 24 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. San Francisco. San Remoi The residents of San Francisco go inland during May, June, and July to get warm; while strangely enough country people come to the city to get cool at this time. The city is supplied with water by the Spring Valley Water Company, and notwithstanding the long period of dry weather each year there has never been any water famine. Nor has there ever been any epidemic traceable to the character of water supplied. The temperature is a little too cool for ocean bathing, but there are large bath-houses at the beach and in the city where salt-water bathing can be had every day in the year. Many of the clubs have large swimming tanks for the use of members. The average rainfall is about 23 inches, and this falls chiefly from November to March. In the past fifty years there was one January when rain fell on twenty- four days; the average number of rainy days in a midwinter (or so- called rainy season) month is about ten. Physicians sending patients to the Pacific coast should remember that marked differences in tempera- ture, humidity, air movement, and sunshine occur within short dis- tances. Near the Bay of San Fran- cisco this peculiarity of climate, is particularly noticeable. Within one hour's ride by boat or rail, from San Francisco, there is often a dif- ference of twenty degrees in tem- perature at the same moment of time and equally great differences in other climatic features. San Rafael offers a pleasant shel- ter from the winds of the coast, while the cities of the Santa Clara valley have just enough of the sea breeze to be delightful summer abodes. Or one can, by going to Mount Tamalpais (elevation 2,500 feet), rise entirely above the fog belt and bask in sun- shine with temperatures ranging from 80° to 90° F. , while at sea level, under the fog, the temperatures are from 55° to 60° F. Alexander McAdie. SANICLE. See Umbelliferm. SANITARY INSPECTION. See Bouse Sanitation. SANOFORM, di-iodo-methyl salicylate, C.Hj.Ij.OH. COOCH 3 , prepared by the action of iodine on oil of win- tergreen, forms a colorless, odorless, and tasteless crystal- line powder. It is insoluble in water or glycerin, and soluble in ether, chloroform, benzol, carbon disulphide, and petrolatum, and in ten parts of hot alcohol and two hundred parts of cold alcohol. Langaard states that it is non-toxic, has no harmful effect on the skin, and is not decomposed by exposure to air, light, or a heat of 200° C. (392° F.). It contains 62.7 per cent, of iodine, and is a substitute for iodoform. Its stability makes it suitable for antiseptic dressings, as they can be sterilized by heat. It is very absorbent, quickly drying up a wound, but forming with the secretions a pellicle which may retain the subsequent secretions and must therefore be soon re- moved. It is employed in the form of a dusting-powder, ten-percent, ointment, or collodion. Radziejewski and Jacobsohn recommend it in ophthalmic surgery. W. A. BoMedo. SAN REMO, ITALY.— This is an Italian town of about 18,000 inhabitants, seven and a half miles east of Bordi- ghera and eighty-four miles west from Genoa. Express trains from Paris run direct to San Remo via Marseilles in about twenty -four hours. It is one of the most fre- quented resorts of the Italian Riviera, and lies upon a small bay formed by Capo Verde and Capo Nero. In the rear are a series of hills and mountain ranges, afford- ing protection from the winds of the north and conduc- ing to the warmth and equability of the climate. The original town is old and quaint, with narrow, steep streets and picturesque architecture. To the east and west is the new town, where are situated the hotels and villas for the winter residents. The English and Americans frequent the west end, and the Germans the east ; it was here that the late Emperor Frederick III. of Germany spent the last winter of his life at the Villa Zirio. In both the east and the west portions of the town are attractive and extensive promenades along the water, shaded by palms, eucalyptus, and pepper trees, that to the west called the Corso dell' Imperatrice, and that to the east the Corso Federico. These promenades afford Fig. 4143.— Shore Drive and Promenade at San Bemo. about the only level walks, for, immediately on leaving the sea, the ascent of the hills begins, so that an invalid is restricted to a limited space about the seaside, unless he rides or is strong enough to walk up hill. The vegetation is varied and luxuriant and of a tropi- cal and semitropical nature— here flourish the olive, lemon, fig, and a great variety of flowers and plants. One is especially impressed with the beauty and abun- dance of the roses and geraniums. The excursions among the hills and valleys are many and varied and through most attractive scenery, with olive, lemon, and orange groves and a profusion of flowers and plants on every hand. The drinking-water is excellent, and the natural drainage must, from the situation of the town, be good. There are also well-built drains running from the new town into the sea or to the mouth of the mountain tor- rents which flow through the narrow valleys to the sea. The soil is of clay, which renders it somewhat damp after a severe rain. The accommodations are abundant and good, although, as at most of the other Riviera re- sorts, they are somewhat expensive. There are competent physicians and all the other requirements of a first-class health resort. The so-called winter season extends from November to April. The chief characteristics of the climate during this winter season are mildness, dryness, and sunshine, with a brilliant blue sky and sea. There is more or less wind, as throughout all the Riviera, and it is sometimes cold. The hills and mountains afford protection from the north wind, but the east and the southeast winds pre- vail. Occasionally the northeast wind blows in winter, as does also the Mistral. Dr. Hassall (" San Remo, Cli- matically and Medically Considered," London, 1883) con- cludes his discussion of the winds by saying that " San Remo, and indeed the whole of the western Riviera, must be regarded as windy. The winds, doubtless on some oc- casions, interfere with the comfort and movements of some invalids, and they constitute a drawback of what is 25 San It. in... Santa Barbara. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. otherwise an excellent climate; but," lie wisely adds, "one must remember that the winds play a very important part, particularly in warm climates, in purifying the air, and exert also for the most part tonic effects on the system." Climate of Sax Bemo. Latitude, 43° 48', for the Season, November to April Inclusive, for Varying Periods. c C s i OJ . to -' , c~. Ofl <£-= 5 -s u d *5 2 O 3 03 0> 71 ^2 o rt ft Temperature, Degrees Fahr.— Average or normal . . 53.54° 49.25° 47.23° 50.19° 52.0° 67.0° 51.55° Average daily range. 10.7 10.4 10.0 7.8 12.1 12.2 11.1 Mean of warmest 61.4 55.5 53.0 56.8 60.5 64.6 58.6 Mean of coldest 50.7 45.1 43.0 49.0 48.4 52.2 47.5 Highest or maximum 66.4 61.9 58.9 62.3 67.1 71.3 Lowest or minimum . 44.2 43.0 36.4 37.0 41.4 45.6 Humidity- Average relative 73. 4? 66.4? 68.7? 68.8? 70.1? 69.8? 69.6? Wind- N. E., N.E., N.W., N. E., N.E., N. E„ Prevailing direction. N. W. N. W. N. E. E. W. W.' N. W. Strong winds (aver- age number days on which they pre- 2.7 1.7 3.7 5.7 . 3 -° 7.0 21.7 M oder a te winds (average number days on which they prevailed) 3.3 4.0 3.7 5.7 10.0 11.3 38.0 Precipitation- Average in inches . . . 5.29 1.13 2.68 1.81 1.18 2.13 14.5 Sunshine — Days of sunshine 24.3 28.3 27.3 25.6 29.6 29.0 164.0 h. m. h. m. h. m. h. in. h. m. h. m. ti. m. Mean daily sunshine. 7 45 6 46 6 26 8 11 8 50 9 12 7 56 The accompanying meteorological table, compiled from data given by Hassall, will convey a fairly accurate idea of the various climatic data for the winter season. It cold, and invalids must avoid either suddenly going from the sunshine into the shade or being out after sunset. The relative humidity is the least — 66. 7 per cent. — at 3 p.m. The mean number of days on which rain falls is 30, and the mean rainfall 14.05 inches for the whole sea- son. The days on which the sun shines are on an aver- age 164 out of a possible 181, and the mean duration of the sunshine is 7 hours and 56 minutes. To the inhabi- tant of northern Europe or the northeastern portion of the United States such an amount of sunshine can hardly be appreciated until experienced. There are many winter resorts, however, in America which afford an equal or greater amount of sunshine, accompanied with a mild temperature. Such are found in Southern California, Arizona, New Mexico, Texas, and in various portions of the pine belt of the South. The general effect of such a climate as that represented by San Remo is thus portrayed by Dr. Hassall (foe. cit.): "Owing to the mildness of the climate," he says, "there is less wear and tear and less strain. The several func- tions are performed in a more moderate and uniform manner. There being less expenditure of power and less waste, _a smaller quantity of food is required, and the stomach has less work to do. The circulation, in par- ticular the heart and its vessels, is exempt from the strains entailed by extremes of heat and cold, and which in themselves are often injurious and not unattended with danger. " The action of the sun on the human body is very complex ; the effects are not confined to the warmth derived from its calorific rays ; the luminous and chemical rays all exert powerful effects. The sun acts as a stimulant to most of the bodily functions — to elimi- nation, secretion, and absorption; it determines many chemical changes, and promotes sanguification and the coloration or bronzing of the skin." With regard to the class of invalids likely to be more Fiu. 4143.— San Reiuo as Seen frum the Mediterranean. will be seen that the average temperature is a high one, and varies but little from month to month, except in April, when it is appreciably higher. The average daily range is moderate, but in the shade and in the early morning and shortly after sunset the air by contrast is or less benefited by this climate, the following may be mentioned: those suffering from pulmonary tuberculosis in its inception or not far advanced, unaccompanied with fever; certain more advanced but very chronic cases es- pecially in persons past middle life, in regard to whom 26 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. San It. inn. Santa Barbara. the only hope is to prolong and make life comfortable ; those suffering from chronic bronchitis, chronic laryngitis, emphysema, and asthma ; cases of diabetes and Bright's disease ; persons suffering from rheumatism and scrofula ; the feeble and aged ; convalescents from acute diseases or from an operation, and all that great army of persons who find existence in the cold changeable climate of the North a constant struggle. The plethoric and those who have a tendency to cerebral hyperemia, those with athe- romatous arteries, and those suffering from functional nervous disorders, such as neuralgia, insomnia, or hys- teria, should not come here. San Remo can now be easily and comfortably reached from America by steamer direct to Genoa from New York or Boston. Here, as in all health resorts, the selec- tion of a residence and the manner of life to be pursued can be satisfactorily determined only by consulting a local physician, which should always be the first thing to be done by the invalid on arrival at any health resort. Edward 0. Otis. SANTA BARBARA, CALIFORNIA.— Santa Barbara, a well-known health and pleasure resort of Southern Cali- fornia, a town of about 8,000 inhabitants, founded in 1782 by Franciscan friars from Mexico, under Father Junipera Serra, is situated in north latitude 34° 24' 30.7", and west longitude 119° 41' 22", on the shores of the Santa Barbara Channel, which body of water is separated from the main Pacific Ocean by the channel islands, Anacapa, Santa Cruz, Santa Rosa, and San Miguel, the average distance of these islands from the mainland be- ing 30 miles. Santa Barbara is 110 miles northwest of Los Angeles and 373 miles southeast of San Francisco, from which points it is reached by the Southern Pacific Railroad and by the Pacific Coast line steamers. The time by rail from Los Angeles is about three and one-half hours, and from San Francisco about eleven hours by ex- press. Santa Barbara lies at the foot of the Santa Ynez Mountains, which rise, on the north of the city, to an al- titude of from 3,000 to 4,000 feet, upon an inclined plane having an area of about 3,000 acres and a maximum alti- tude of 200 feet. The inclined plane slopes in a southerly and westerly direction to the sea, at the rate of about 100 feet to the mile, thus insuring good drainage to the town. This inclined plane is bounded by the foothills of the Santa Ynez Mountains on the north, and on the south and southwest by a so-called "mesa," or^ table- land, about 400 feet high, which intervenes between the city and the channel, and on the southeast by the chan- nel itself. The soil upon which the city rests is com- posed chiefly of clayey loam, and is generally very dry, owing to the difficulty with which rains penetrate be- neath its surface. Santa Barbara is noted for the elegance and refinement of its social life, whose leaders have migrated from older social centres, and is annually visited by thousands of travellers from all parts of the world. The facilities for amusement and recreation at Santa Barbara are numerous, embracing horseback riding over broad lowland roads, by the sea, or on mountain trails, pedestrian tours among the mountains, driving, polo, golf and tennis, for the cultivation of which sports special clubs exist. There are two city clubs and a country club, which generously extend many courtesies to visitors. The country club- house is delightfully situated by the sea in Montecito, a suburb of Santa Barbara, about three miles from the centre of the city. There are numerous hotels and boarding-houses in Santa Barbara, offering accommodations commensurate with the means of all comers. . The Hotel Potter, of immense proportions and fully equipped with every comfort and luxury, has been recently erected (1902) near the shore ; and the Arlington, situated about a mile from the water front, affords suitable accommodations for those who do not wish to live in close proximity to the sea. There are numerous cottages and houses, furnished and unfur- nished, which may be rented by those who desire to have private establishments of their own. A new bathhouse, located on the shore, at the Plaza del Mar, affords good facilities for bathing in both hot and cold sea water all the year round, and has dressing-rooms for those bathers who prefer a plunge into the sea. During the summer the temperature of the sea water varies from 68° to 74° F. , and it is rarely below 60° F. in the winter months. The Cottage Hospital, an institution for the treatment of all classes of medical and surgical cases, is situated at Oak Park, a quiet western suburb of the town. It is supported by voluntary contributions and has a training- school for nurses. The superintendent is a physician, but there is no regularly established corps of attendants, each patient being at liberty to be treated by his own physician. A well-known private sanitarium, Miradero, crowns the heights beyond the western end of the city, and is fully equipped with all modern appointments for the entertainment and the treatment of invalids and con- valescents. The city is lighted by gas and electricity, and an electric street railway gives easy access to all parts of the town. Santa Barbara has three daily pa- pers, a free public library, churches of the leading de- nominations, a chamber of commerce, and a good system of free schools, besides separate private schools for boys and girls and a manual training-school. The water sup- ply of Santa Barbara is derived from the creeks in the mountain cafions and from artesian wells. The climate of Santa Barbara is characterized by remarkable mild- ness, notable uniformity of temperature, abundant sun- shine, low relative humidity, and low average velocity of the wind, advantages which it owes to its low lati- tude, and its sheltered position, to the topography of the surrounding country and to the proximity of the sea. There is no governmental station at Santa Barbara for the study of climatic conditions, but competent and care- ful meteorologists have recorded their observations for the last thirty-two years, and the accompanying table embodies their results : Averages of Temperature (Degrees Fahr.) Rainfall, Rela- tive Humidity and Wind Movement at Santa Barbara, Cal., During the Past Twenty-Five Years (Ending 1902). Month. §5-aS? 8c>.g-g gS^ %tZ 8.5 £> I g S a° January... February . Mareb April May June July August . . . September October ... November December. Means... ?al a>_: *S,r?& 5Pa> i b s&a| is a §"3 rsst gsss g+ii; a> S fe S3 <* a onin (CasHaaOio), is about three or four times as active as either of the preceding. Like parillin, it is crystalliza- ble, while smilasaponin is not. These constituents are all more or less soluble in water or alcohol, more so upon the application rjf heat. Either the decoction or a prepa- ration with a warm mixture of alcohol and water well represents the drug. The constituents are fatal to ani- mals, with the general symptoms of poisoning by the sapotoxins. Action and Use. — Sarsaparilla was first carried to Europe about 1536-45, and first or early employed as a cure for the same disease with which it has been since most generally associated, and for which another smilax, " China," had previously been used. The use in numer- ous other slow diseases, especially in eruptions and as a " blood purifier " in general, followed, and has continued extensive until the present time. Although now it has been nearly discarded as a serious medicine by physicians, it is still a much-prized popular remedy, and is exten- sively used, the world over, for syphilitic and scrofulous diseases. Its reputation is doubtless greatly and unduly enhanced by the enormous popular advertising of numer- ous proprietary articles bearing its name, but in reality quite different substances. On the other hand, there can be no doubt that the judicious use of sarsaparilla by phy- sicians should be extended. The valuable depurative effects of the saponins, not only by promoting excretion by the intestines, but through most other channels, re- quires no argument, and the timely use of a laxative dose of sarsaparilla, perhaps at the soda fountain — if only a genuine article could be there expected, — may well pre- vent the necessity for more violent treatment later on. The dose of any preparation should represent from 4 to 8 gm. ( 3 i. to ij.). The Pharmacopoeia provides a fluid extract ; a compound decoction of ten-per-cent. strength, with two per cent, each of sassafras, guaiac wood, and liquorice root, and one per cent, of mezereum; a com- pound fluid extract of seventy-five-per-cent. strength, with twelve per cent, of liquorice root, ten per cent, each of sassafras and glycerin, and three per cent, of meze- reum. Allied Product. — China root, from Smilax China L., in large, hard, jalap-like tubers, is used in the East for the same purposes as sarsaparilla. Henry H. Busby. SARSAPARILLA, See Araliacem. FALSE. {Aralia medicaulis L.) SASSAFRAS, U. S. P.— Sassafras bark. The dried bark of the root of Sassafras Sassafras (L.) Karsten. (S. variifolius [Salisb.] Kuntze — fam. Zauracem). Although all parts of the sassafras tree are aromatic, the bark of the root is selected for official purposes because its aro- matic properties differ in kind from those of the leaves and branches, and are far stronger than the similar prop- erties of the bark of the trunk and the wood of the root and trunk. The British Pharmacopoeia makes the root, Fig. 4155.— One of the Three-Lobed Leaves of Sassafras. (Baillon.) the German Pharmacopoeia the wood of the root, official, while certain others include, or even specify, the wood of the trunk or at least of its lower portion. There can be no question that the official article of the United States Pharmacopoeia is very superior to any other part of the plant. The sassafras tree grows very abundantly in light soil and exposed or partly exposed situations from east- ern Canada southward, being collected chiefly in the coast region. It occasionally reaches a height of seventy feet or more and a trunk diameter of upward of three feet, though usually its height is from twenty-five to 41 Sassy Bark. Scabies. REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. forty feet and its trunk diameter little more than a foot. The root is much and irregularly branched. When it is freshly dug, its outer color is whitish and its -wood yel- lowish or brownish- white, but the former soon turns gray and the latter of a rusty red or brown after collection. Annual rings are apparent in cross section, though less conspicuous than in most trees of the same region. The bark of the trunk is ashy gray and deeply Assured ex- ternally, whitish within, goon turning rusty brown, though not so deeply as does that of the root. The wood of the trunk is similar to that of the root, though less deeply colored. The young twigs are at first deep green and smooth, gradually becoming brownish- warty, then brown and fissured with ago. The large pith of the branches is described below. The form of the leaf is dis- played in the accompanying cut, though often not lobed or with a lobe on only one side. The leaves are thin and downy when very young, soon becoming thickish and smooth. The dioecious, small, yellowish flowers are borne in umbels or corymbs, and appear somewhat before the leaves. All parts of the tree are aromatic, bitter, and strongly mucilaginous. The drug is thus described : In irregular, warped, chip-like fragments, 5 mm. (£ in.) or less in thickness, the thicker pieces deprived of most of the gray corky layer; bright rust-brown, or with more or less of the gray-brown cork adhering and exhibiting its outer surface softly and rather finely scaly, from numerous short, intersecting, shallow fissures ; inner sur- face obscurely short-striate ; light, soft, and fragile, with a short, weak fracture which exhibits a broad, irregular, whitish layer between two rust-brown ones ; strongly and peculiarly fragrant; taste sweetish and bitterish, aro- matic, mucilaginous, and slightly astringent. The stem-bark is in strips or elongated pieces, with a lighter-gray, more deeply and longer fissured outer surface, and is less aromatic, more mucilaginous and bitter. The most important constituent of sassafras is its vola- tile oil, of which there is sometimes nearly ten per cent. When fresh, the bark contains a large amount of a pecul- iar tannin, which, after collecting, gradually becomes converted into the peculiar granular yellowish -brown substance, sasaafrid, which is readily dissolved in alcohol. A large amount of starch, much gum, and an unstudied bitter principle also exist. The properties of sassafras are almost wholly referable to its volatile oil. No prep- aration of it is official, but it is largely used in the house- hold, and to some extent by physicians, as a stimulating diaphoretic and as a deobstruent or alterative ("blood purifier "), stimulating the excretions of the kidney and skin. For these purposes, the infusion is commonly em- ployed. It should have a strength of five per cent., and may be taken in wineglassf ul doses. Oil of Sassafras (Oleum Sassafras, U. S. P.) is defined as a volatile oil distilled from sassafras, and it is directed to be kept in well-stoppered bottles, protected from light. Although thus defined as obtained from official sassafras, it is really obtained from the entire root, the wood of which yields from one and one-half to two per cent. It is thus described by the Pharmacopoeia : A yellowish or reddish-yellow liquid, having the char- acteristic odor of sassafras without the odor of camphor, and a warm, aromatic taste. It becomes darker and thicker by age and exposure to the air. Specific gavity: 1.070 to 1.090 at 15° C. (59° F.). Soluble, in all proportions, in alcohol, the solution be- ing neutral to litmus paper ; also soluble, in all propor- tions, in glacial acetic acid, and in carbon disulphide. If to five drops of the oil five drops of nitric acid be added, a violent reaction will take place, producing at first a red color, and finally converting the oil into a red resin. If to a few drops of the oil a drop of sulphuric acid be added, a deep-red color will be produced at first, which soon becomes blackish. The oil consists chiefly of safrol (CmHicO.,), with a small amount of safrene (d H le ) and a very small amount 42 of eugenol. Safrol fully represents the properties of the oil. Oil of sassafras differs but little in its action and uses from ordinary stimulating volatile oils, for example, oil of peppermint. Although an active carminative, it is scarcely so efficient as oil of peppermint or oil of anise in that direction. On the other hand, it appears to be rather more freely excreted through the skin and a more efficient diaphoretic. It is also distinctly laxative and its reputation for stimulating the excretory functions appeal's to be justified. The dose of this oil is one to five minims. There is no official preparation. Sassafras pith (Sassafras medulla, U. S. P.) is defined as the dried pith of the sassafras andis thus described: In cylindrical, straight, curved, or coiled pieces, one to several inches in length and 3 to 8 mm. (| to £ in.) in diameter, or in split portions of the same; white, very light, and spongy ; inodorous or with a slight odor, as well as taste, of sassafras; very mucilaginous. Macerated in water, it forms a mucilaginous liquid, which is not precipitated on the addition of alcohol. Its aromatic content is entirely insignificant and it is valued wholly for its gum, which readily forms a muci- lage upon maceration with water. This mucilage pos- sesses the important property of mixing with alcohol without precipitation, and it becomes a useful vehicle for the administration or application, especially to the eye, of active substances. Its properties in general are merely those of mucilages. Its mucilage is official and is directed to be made freshly, when wanted, by macer- ating 2 gm. of the pith in 100 c.c. of water for three hours and straining. Several other vegetable products are called sassafras in other countries, but none of them is of interest in our Materia Medica. Henry U. Rusby. SASSY BARK.— Manama Bark. The bark of Ery- fhrophleum Quineense Don. (Fam. Leguminosce), a good- sized, acacia-like tree, growing in tropical Africa, and employed by the tribes of the west side like Calabar beans, as an ordeal. It was made known in Europe and America about forty years ago, and was revived as a medicine about ten years since. It is a ponderous bark, heavier than water, of a dull red color, a fissured exter- nal surface, and a short fracture. Odor slight, taste as- tringent. The active principle of sassy bark is erythro- phleine, a crystalline alkaloid, first obtained by Gallois and Hardy. It is an active heart-poison of the digitalis kind, producing slowing of the pulse, increase of blood pressure, and in experiments upon animals death, with the heart in systolic contraction. The powdered drug is a powerful sternutatory. But little use has been found for this potent medicine. It is sometimes used like digi- talis, in doses of one to three grains, of the bark, in the form of a tincture, but is far less certain and regular and even more inclined to upset the stomach. It is said to be employed at home in dysentery, etc., with benefit, as well as in intermittent and other fevers. In full doses it is nauseating and emetic, as well as somewhat nar- cotic. Allied Plants, etc.— See Senna. W. P. Bolles. SAUNDERS, RED.— Santalum Rubrum, U. S. The heart-wood of Pterocarpus santalinus L. f. (fam. Legumi- This article, often called ruby wood or red santal, is the product of a small tree of India, collected chiefly in the Madias Presidency, and now mostly from cultivated plants. The wood is imported in billets three or four feet long and from two to eight or nine inches in diam- eter, the bark and sapwood having been removed. It is of a bright blood-red color within, but darker upon the surface, becoming at length nearly black with age and exposure. For pharmaceutical use, it is usually cut into chips or rasped into powder. It is almost odorless and has only a slight astringent taste. Its coloring matter is santalin or santalic acid, crystallizing in minute red prisms, soluble in alcohol, ether, alkalies, and a few es- REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Sassy Bark. Scabies. sential oils, but not in water, which is scarcely colored by red saunders. The article ia essentially a dye-stuff, being without physiological or medicinal power and used purely for coloring purposes, as in the compound tincture of lavender, which contains about one per cent, of it. W. P. Bolles. SAVILL'S DISEASE. See Dermatitis Bpidemica. SAVINE — Sabina, D. S. P. The leaves and young twigs of Juniperus Sabina L. (fam. Pinacem or Coniferce). This is a compact, horizontally spreading, evergreen shrub or small tree, resembling our com- mon red cedar on a small scale, and bear- ing similar berries. It is widely distrib- uted through the north temperate zone of the Old World, and is also met with in the i Northern United States (in the Great Lake region) and in Canada. The medi- cal supply comes from Europe, chiefly from Switzerland, in " short, thin, sub- quadrangular branchlets, the leaves in four rows, op- posite, scale - like, ovate, lanceolate, ses- sile, more or less acute, appressed, im- bricated, bearing on the back a shallow groove containing an oblong or roundish gland ; odor peculiar, terebinthinate ; taste nauseous and bitter. " The odor and taste of savine are mostly due to from two to four per cent, of es- sential oil (Oleum Sa- bina!, U. S. P.), a pale-yellow, terebinthinous liquid, becoming thicker and darker by age, colorless if redistilled, of a specific gra- vity of about 0.910. It has the odor of savine, a sharp, bitter, camphoraceous taste, and is more rubefacient and irritating to the skin than others of its class. Tannin and resin are less important constituents of savine. Action and Use. — Savine and its oil are essentially like, but more intense than, oil of turpentine in physio- logical and therapeutical properties; irritating to the skin and mucous membranes, to the urinary apparatus by which they are eliminated, and to the uterus, which they may cause to abort. Besides these effects, convul- sions and coma may follow. Vomiting, diarrhoea, gastro- intestinal inflammation, strangury, with or without con- vulsions or unconsciousness, these are the usual symptoms of savine poisoning ; abortion may or may not take place. This potent drug is not much employed. It has been given as an emmenagogue, also as a haemostatic, for leu- corrhcea and other purposes mostly connected with the uterus. It is hot infrequently used with criminal intent to produce abortion, usually without success, unless it nearly or quite kills the mother also ; externally it is the basis of some moderately useful stimulating ointments, liniments, and "hair-restorers." In this country, the oil of juniper, which is milder, is perhaps generally substituted for oil of savine. Oil of turpentine is also often substituted for or mixed with it. Oil of savine can be distinguished by the fact that it does Fig. 4156.— Savine, Fertile Branch. (Balllon.)' not form a solid mass with hydrochloric acid ; also by the fact that very little of it distills under 200° C. The dose of savine (leaves) is about 0.5 gm. (gr. viij.); of the oil, from one to four or five drops. A fluid extract of the former (Ex. Sabince Fluidurn, U. S. P.) is an eligi- ble preparation and the basis of the cerate (Ueratum Sa- bina, U. S. P.), strength about 25 to 100 savine. W. P. Bolles. SAVORY, SUMMER. See Labiatm. SAW PALMETTO.— This palm, Serenoa serrulata, forms the common palmetto scrub of South Carolina, Georgia, and Florida. The whole plant has marked de- mulcent and nutritive properties, and is extensively used as a local remedial agent in all forms of disease of the mucous membranes, especially when associated with de- bility and wasting. Its use is followed by an improved digestion, increased strength and flesh, and a soothing influence on any irritable state of the membranes. It is used in catarrh, ozsena, and bronchitis, and has a special value in diseases of the bladder and reproductive organs. Reginald Harrison ' has found it very beneficial in irri- table states of the bladder, and compares its action to pareira. It is also reported to be of benefit in affections of the prostate gland. Another property that is claimed for it is its vitalizing and strengthening action upon weakened and wasted glands of the generative organs. It is said to cause a rapid development of the mammoe, ovaries, and testes, when these organs are debilitated as the result of masturbation and sexual excesses of all kinds. The berries and seeds contain a large percentage of a fixed oil, upon which the medicinal properties are said to depend. 2 The fluid extract of the seeds is the most con- venient form for administering the drug ; it is given in half -drachm to one-drachm doses, repeated three or four times a day. Beaumont Small. 1 London Lancet, 1890, 414. * Phar. Review, 1897, 113. SCABIES (Latin, scabies, an itching eruption, from scabo, Iscratch). — Synonyms: The Itch; German, Kratze; French, Gale. Scabies is a contagious disease of the skin, wholly local in character, due to the presence of an animal parasite — the acarus or sarcoptes scabiei (see Arachnida, in Vol. I.) in, and upon, the skin. The erup- tion present may vary from the smallest amount imagin- able, a few papules, up to the most severe development of inflammatory lesions, even such as to render the pa- tient helpless ; the subjective sensations may vary from a slight pruritus, which is described as not unpleasant when relieved by scratching, up to an itching which is almost unendurable, causing restless nights and distress- ing days. The most common sites for the lesions of scabies are the hands, especially about the wrists, in the soft skin between the fingers, and on the sides of the hands. But in many cases the eruption is entirely absent from this locality and is well marked elsewhere. In males the pe- nis seldom escapes, and in females the region of the nip- ples is very apt to be affected ; ■ the anterior fold of the axilla is a very common seat of the lesions, and the el- bows and extensor surface of the forearms are sometimes most severely affected. In those who sit a great deal the buttocks often present an abundant eruption. In in- fants and children the softer parts of the feet and ankles generally exhibit lesions. It may be said that the head is never affected by scabies. The eruption of scabies exhibits the greatest variety of lesions, from the smallest papules and vesicles to large pustules, often ecthymatous in character, and in weakly children pustular bullae may form on the hands. The bulk of the lesions is papular, although small vesicles can generally be seen on tender portions of the skin dur- ing some period of the disease. Mingled with these pri- mary lesions there are generally found the results of scratching, viz., abraded surfaces and those covered with crusts. 43 Scammony. Scapula, REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. The only single pathognomonic sign of scabies is the cuniculus, furrow, or burrow (German, Milbengang ; French, sillon), which is caused by the penetration of the female beneath the epidermal layer of the skin in the search of a place where she may lay her eggs; the male seldom, if ever, goes beneath the skin. This cuniculus consists of a minute, dark -colored line, generally some- what beaded in appearance and curved, appearing much as if a bit of dark sewing-silk had been run beneath the sur- face ; rarely, it is as long as a fourth of an inch, more often half that length ; and generally it may be seen to terminate at one end in an inflamed papule or vesicle, or sometimes to run over a pustule. The female insect will be found at that end of the furrow, and the dark line is her track, which is found to be filled with eggs in various stages of development, and, among them, black particles of faeces. If the skin is washed these dark lines, instead of being re- moved, become more apparent ; but in recent cases, or in individuals who are very cleanly or have undergone treat- ment, it is often impossible to discover any of these cuni- culi, although the disease may still exist, and, if left alone, itwill increase and may be communicated to others. Scabies is not a very frequent disease in this country, forming only about 1.5 per cent, of a large number of skin cases analyzed. In other countries it is more com- mon, and in Glasgow it formed twenty-five per cent, of ten thousand cases analyzed by McCall Anderson. Diagnosis. — Considerable care is often required to diagnose a mild or unusual case of scabies, and cases sometimes go unrecognized for a long time. The disease most commonly confounded with it is eczema, which may present almost identical appearances, except that there are no cuniculi; when these latter are positively found the diagnosis is certain. The location and distri- bution of the eruption, the history of contagion, and the multiform character of the lesions are generally sufficient to establish the diagnosis. Scabies may also be con- founded with lichen, pityriasis, prurigo, pruritus, and urticaria papulosa. Etiology. — There is but one cause of scabies, the pres- ence of the parasite (acarus or sarcoptes scabiei - !, whose removal or destruction is followed by the cessation of the disease. It often occurs, however, that the treatment employed may occasion an amount of artificial eruption or dermatitis which may mask the true affection, and may even remain after the real cause of the disease has been destroyed ; this second eruption may require a very different treatment, of a soothing character. Pathology.— The only pathologial lesions, aside from the presence of the cuniculus, are those connected with inflammation of the skin. The lesions are simply inflam- matory areas of greater or less size, caused either by the direct irritation of the burrowing insect, or by the scratching or other measures employed for the relief of the itching, or by both. When the local irritation is re- moved the eruption ceases; if the acari could all be re- moved mechanically, picked out, there would be no erup- tion. In patients who are paralyzed on one side, or who have been unable to scratch, there is very little eruption on the portions of the skin which are out of reach. Tbeatment.— The treatment of scabies is purely loeal. and consists in such measures as destroy the life of the parasitic insects and their eggs. The patient first takes a warm bath, using plenty of strong soap rather alkaline in character, such as the sapo viridis or the common laun- dry soap, and rubbing the affected parts so as to break the furrows as much as possible. After drying, the affected parts, or even much of the body, should be well rubbed with an ointment of which sulphur is a chief ingredient. The ordinary sulphur ointment diluted once, with the ad- dition of a drachm of liquid storax to the ounce, answers as well as anything. After thorough friction with this for at least half an hour, the patient puts on underclothes which are to remain on night and day until the end of treatment. The ointment should be freshly rubbed in twice daily for several days, and a bath is to be taken on the third clay, the ointment being again rubbed in and a fresh suit of underclothes put on. After three days more of treatment another bath may be taken, and it is then to be expected that the cure is complete. But frequently some of the cuniculi will be found to have escaped being broken, or new infection may come from the clothing or elsewhere, and in such case the treatment must be re- peated. Sometimes an artificial eruption is excited by the treatment, when soothing remedies are required. The clothing should always be treated ; the underclothes should be boiled a long time and very thoroughly ironed ; the outer garments may be baked or very thoroughly ironed on the wrong side. Patients should be more or less isolated, although when they are under treatment the chances of communicating the disease are very small. Prognosis. — The prognosis is, of course, favorable; there can never be the slightest harm in curing even the most inveterate or severe cases of scabies. In the hospi- tals abroad it is claimed that a cure is effected in a few hours, but it is questionable if, in the large majority of cases, the relief is more than temporary, a portion only of the parasites being killed. Practically, cases require treatment for a number of days, or even weeks, to make the cure certain; when the skin is delicate the active parasitic treatment may have to be interrupted, owing to the dermatitis excited, and occasionally it will be found difficult to use remedies strong enough to effect a cure. L. Duncan Bulkley. SCAMMONY.— (Scamrnonium, U. S. P., B. P.) A res- inous exudation from the living root of Convolvulus Scam- monia L. (fam. Convolmlacem). This is a perennial herb of the Levant, having a long, thick, cylindrical, several- headed, but otherwise usually simple, milky -juiced root, and numerous twining stems, resembling those of an ordi- nary morning-glory vine. The root, which is official in the British Pharmacopoeia, is up to a metre in length, and a decimetre in diameter, at the crown, light browiiish- yellow without, white within, fleshy, and resinous. The scammony is collected by cutting off the living root at the crown and either scraping ofE the exudation as it appears or placing some receptacle, commonly a mussel shell, at the lower side to receive it as it runs down. It may dry at once, a very high grade of the drug thus re- sulting ; or, as is more usual, the separate collections are laid aside until enough is accumulated to make a "cake," when it is all moistened and kneaded together. In this way the bubbles and sour odor of what is known as " Vir- gin scammony," are produced. Scammony is in irregular, angular pieces, or circular cakes, greenish-gray or blackish, internally porous and of a resinous lustre, breaking with an angular fracture; odor peculiar, somewhat cheeselike; taste slightly acrid; powder gray or greenish-gray. The porous, bubbly texture and the sour, cheesy smell are results of fermen- tation during the process of drying. It is soluble to the extent of three-fourths in ether. The costliness and opaque color of scammony render it especially liable to adulteration. Lime, flour, ashes, gum, etc., are among the common admixtures. The proportion of resin is the best test of purity. This resin (Besina Seammonii, U. S. P.) is obtained by digesting the drug with alcohol and evaporating the tincture so obtained, or by treating the root in the same way. It is a brown, translucent brit- tle resin, with a sweet fragrant odor if obtained from the root ; but, as is usually seen, from crude scammony, it is more greenish and dirty in color, and has the odor of scammony itself. In action and value the two products are about the same. Composition.— The peculiar resin of scammony, un- fortunately called jalapin, and now known as scammonin, first obtained in a state of purity by Johnston, in 1840, differs from the conwlvulin of jalap by its solubility in ether. When purified, it is a colorless, translucent, brittle non-crystalline resin, tasteless and odorless, of nearly neutral reaction, and freely soluble in ether. It is a glucoside, and resolvable into scammonic acid, a crystal- line substance, and sugar. Good scammony contains eighty or ninety per cent, of this resin. 44 REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. Scammony, Scapula. Action and Use.— Soammony and its resin are to be counted among the very active drastics, excelled only by croton oil and elaterium. Their action is similar to that of jalap, but considerably more intense. They are used as derivatives and hydragogue cathartics in cases of car- diac and renal troubles associated with dropsy. The ac- tion of scammony resembles that of jalap, but is more intense. Aromatics and carminatives are appropriate adjuvants. Dose, of good scammony, half a gram or so; of the resin, 3 or 4 dgm. The compound extract of colocynth contains fourteen per cent, of resin of scam- mony. W. P. Bolles. SCAPULA, SURGICAL AFFECTIONS OF THE.— Diseases of the Scapula. — Acute periostitis and osteo- myelitis of the scapula are rare. When present they are usually the result of traumatism followed by infection, and affect most commonly prominent portions of the bone, such as the spine. Tuberculous osteomyelitis of the scapula is much more common and may give rise to extensive caries and necro- sis. Cold abscesses may form and reach the surface at some distance from the focus in the bone. In rare cases the shoulder-joint may become involved. The treatment of tuberculous disease will depend upon the extent of the local process. Small foci may be scraped out with the Volkmann spoon and treated later by iodoform injections. Larger foci may require resec- tion of a part of the bone, such as a portion of the body or the spine. Complete excision of the scapula is seldom indicated. Tumors of the Scapula may be either benign or malignant, the latter being the most common. A recent collection of 64 cases made by Langenhagen showed the following relative frequency : Exostosis, 8 ; chondro- ma, 14; fibroma, 5; carcinoma, 23; sarcoma, 12; uncer- tain tumors, 2. The tumor may reach an enormous size, and in case of the malignant varieties the surrounding parts may be- come invaded. Some tumors grow into the axilla, others spread to the adjacent muscles, and may eventually ulcerate through the skin. Metastases may occur in the pleura, lungs, vertebrae, or some other internal organ. The treatment of malignant neoplasms consists in excision of the scapula provided that the tumor has not involved the arm. In the latter case removal of this as well may be indicated (interscapulo-thoracic ampu- tation). Benign tumors, when circumscribed, may be removed by partial resection of the portion of bone involved. The usual incision for excision of the scapula begins over the acromion, runs along the spine to its inner border and there descends to the angle. Through this incision the muscular attachments are divided close to the bone, and the whole bone is removed. If possible that part of the acromion should be preserved which receives the inser- tions of the trapezius and deltoid muscles. Otherwise the function of these muscles will be lost. Phactures of the Scapula. — These are compara- tively rare injuries (according to various authors from one to four per cent, of all fractures), and occur chiefly in adult males. The following varieties of fractures occur : 1. Fracture of the body of the scapula (including one of the angles). 2. Fracture of the glenoid cavity. 3. Fracture of the neck. 4. Fracture of the acromion and spine. 5. Fracture of the coracoid process. 1. .Fractures of the Body are the most common. They occur usually in the infraspinous fossa, and the line of fracture is most commonly transverse. The cause is blunt violence, such as a blow or fall, and there may be considerable contusion of the overlying soft parts. In case of multiple fractures, there may be several fissures radiating from a central point. Fractures of the lower angle form a comparatively common group of fractures of the body, and may be accompanied by considerable displacement of the small lower fragment. Fractures of the upper angle are far less frequent. The objective symptoms of fractures of the body are, as in other fractures : crepitus, false motion, and localized tenderness. These signs arc not always easy to make out, especially in muscular subjects or in case of marked swelling. The scapula can be brought into prominence and thus bo easier to palpate if the elbow is drawn in- ward in front of the chest or the arm carried backward and inward. Dislocation of the fragments is most marked in fractures of the lower angle, and is then due to the combined action of the teres major and serratus magnus muscles upon the lower fragment. The prognosis of these fractures is good. Bony union usually takes place promptly under proper immobiliza- tion, and the function of the arm is not impaired. In the rare cases of compound fracture suppuration may occur, and the pus may burrow downward between the scaptila and the muscles of the back. The treatment consists in immobilization of the shoul- der and scapula in that position which overcomes the de- formity. The arm can be kept in this position by means of a Velpeau bandage to which may be added some turns of a plaster-of -Paris bandage. In about four weeks the fracture should be solid and movements of the arm may be begun. KOnig recommends in some cases suture of the fragments. 2. Fractures of the Glenoid Canty . — These are rare fractures which may involve chipping off of some portion or of the whole of the articular surface (fractures of the anatomical neck). They are sometimes associated with dislocation of the humerus. The symptoms are very ob- scure, and it is doubtful if a diagnosis can be made. As a dislocation of the humerus is often present, the treat- ment would be that of the dislocation. 3. Fractures of the Neck of the Scapula are of consider- able practical importance. The line of fracture runs downward from the incisura scapulae. The causes are usually some form of direct violence applied to the shoul- der region, such as a blow or fall. The symptoms resemble somewhat those of dislocation of the head of the humerus. There are a flattening of the shoulder and abduction of the arm ; the acromion is prominent, and the axis of the arm is not directed toward the shoulder- joint. The chief point of difference is that the fractured piece can be felt in the axilla as an irregular object not resembling the smooth head of the humerus. By grasping the coracoid process with the middle finger and the posterior aspect of the shoulder with the thumb, crepitus can be felt on rotation of the arm. Crepitus can also be felt by palpation in the axilla. The deformity of the shoulder can be readily overcome by upward press- ure ou the fragments within the axilla, but recurs again as soon as pressure is stopped. In dislocation of the shoulder, on the other hand, the deformity is made to disappear only by special movements for reposition of the head of the bone. The treatment consists in replacing the fragment by upward pressure and maintaining it in place by a pad in the axilla. The arm is secured to the body by means of a Velpeau bandage. Plaster bandages may be applied as an outside dressing. The fracture sometimes re- quires as long as from ten to twelve weeks for consoli- dation. 4. Fractures of the Acromion and Spine are produced by direct violence upon these prominent portions of the bone. The line of fracture is usually transverse. The most important symptoms are the irregularity in the out- line of the bone, localized tenderness, and occasionally crepitus. In case of the acromion, the fracture lies either in front of the acromio-clavicular joint or near the base of the acromion. The outer fragment may be displaced downward from the weight of the arm. The treatment of fractures of the spine consists in immobilization of the arm in a flexed position. In fractures of the acromion the outer fragment is elevated by pressing the humerus up- ward. It is retained in position by means of a bandage 45 Scarlet Fever. Scarlet Fever. REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. bound around the shoulder and body or by an adhesive plaster strip supporting the elbow and crossing itself over the point of fracture. 5. Fractures of the Goraeoid Process. — These are very rare and are usually combined with some other fracture or dislocation in the vicinity. The fracture is usually near the base of the process, and results most commonly from direct violence, although muscular contraction has been known to produce it. The chief symptoms are local swelling, ecchymosis, abnormal mobility, and crepitus. Pain can be elicited by flexion of the forearm in a supinated position, as this brings the short head of the biceps muscle into action. _ The treatment consists in immobilization of the arm in a flexed position by means of a Velpeau bandage. Benja/min T. Tilton. SCARLET FEVER.— Synonyms: Scarlatina (English and Italian); Scharlach (German); Scarlatine (French); Escarlatina (Spanish). Definition. — Scarlet fever is an eruptive contagious fever. Its incubative period is brief, rarely less than twenty -four hours, usually lasting for from four to six days, and not often exceeding this duration. This period is succeeded by a period of invasion, which is ushered in by fever, usually of considerable intensity, and by sore throat. A scarlet eruption begins to appear before the end of the second day, and marks the end of the prodro- mal, and the beginning of the eruptive, period. The eruption rapidly becomes general, and the tongue be- comes stripped of its coating and assumes a raspberry- red color. The eruption slowly fades after the first few days. The fever persists until the sixth, seventh, or eighth day, or longer. As the eruption fades, desqua- mation begins and continues for from eight to fourteen days or more. It is peculiar in being lamellar, sometimes occurring in very large shreds and exfoliations. During the attack, and for weeks subsequently, there is an espe- cial predisposition to renal inflammation. Scarlet fever attacks children more especially. It usually affects an individual but once. History. — Scarlet fever is probably a disease of very ancient origin, though until three centuries ago medical writers had not recognized it ; indeed, definite knowledge of it as a specific, independent affection dates back hardly two hundred 3 r ears, although as early as 1589 an epidemic, which we now presume to have been scarlet fever, was described as having occurred in Sicily in 1543 (Paulus Restiva). 1 It was not until 1676 that Sydenham defi- nitely separated this malady, as "febris scarlatina, " from measles, and gave it an established position. The obser- vations of writers had already been leading them toward similar views, and within a few years scarlatina became recognized all over Europe. Although its place of origin can never be known, it is probably of European birth ; for it is a remarkable fact that scarlet fever has never succeeded in gaining a firm foothold in Asia or Africa. According to Hirsch, in whose most valuable work these facts have been recorded, the coast of Asia Minor is the only Asiatic district which is frequently visited with scarlatina in its severe forms. In nearly all other parts of Asia it occurs not at all, or only sporadically. Wer- nich, in 1871, declared the disease to be quite unknown there. In Africa, Hirsch states that it is only in Algiers and in the Azores that it is at all common. Following the carefully_ recorded data of Hirsch, scarlet fever ap- peared first in America, in New England, in 1735. It extended as far south as Philadelphia in 1746, and pene- trated to Ohio in 1791. Not until 1851 was it seen in California. In 1830 it began to be generally observed in South America. In the West Indies it was first observed in 1802, in Martinique, as a mild epidemic. Greenland has heretofore escaped with but a solitary case. Aus- tralia and Polynesia appear to have escaped until 1848. In the Polynesian islands, except Tahiti, scarlatina has not been known. It is unquestionable that scarlet fever has never occurred in some localities only because the in- habitants have not been exposed to its influence; but there can be no doubt that in other countries influences prevail that oppose the development of the disease. Whether these are climatic or racial, or due to pther causes, is at present unknown. The American Indian is not exempt from its ravages, nor can any different de- gree of susceptibility be observed in the negro race in the United States. Frick, 8 however, noted a somewhat more pronounced tendency in the negro to scarlet fever. In the epidemic in Baltimore, between the years 1850 and 1854, of every ten thousand inhabitants 13.8 whites and 10.8 negroes died. This would indicate a relatively greater predisposition in the negro, as in the total popu- lation the whites were largely in the majority. Frick's observations were too limited to secure an unhesitating acceptance of his conclusions. It must be noted, how- ever, that in this country the negro is rarely of unmixed African descent. He may have inherited from white progenitors some of their especial liabilities to disease. Drake and others have shown that scarlet fever prevails less in the Southern than in the Northern States. It is also probably true that the disease is more frequent in cold than in hot countries. Yet it cannot be determined that the differences depend upon temperature ; Greenland has remained without an epidemic, while Algiers has ex- perienced them frequently. In 1873-75 a severe epidemic of scarlet fever appeared in the Faroe Islands, among people who for at least fifty -seven years, and possibly never before, had not been exposed to scarlet fever. ,9 The study of this epidemic, to which reference will frequently be made, gives one interesting data as to the natural, course of the disease in a community in which each indi- vidual may reasonably be presumed to have been ex- posed, and in which immunity, due to previous attacks, can be excluded. Frequency of Epidemics. — Scarlet fever at once shows differences from smallpox and measles in not sweeping over localities in great periodic waves. It may, it is true, sometimes invade very wide areas of ter- ritory with astonishing rapidity, but the intervals be- tween epidemics are often very great. Without obeying any well-defined periodic law, measles is often known to prevail with noticeable violence every third or fourth year, frequently disappearing completely in the interim ; so, too, smallpox usually exhibits unwonted activity at intervals of from five to ten years, or as soon as popular neglect of vaccination renders a large portion of a com- munity susceptible to it. It is not thus with scarlatina. Hirsch has collected very valuable information upon this point. At Munstcr fifty years elapsed without the dis- ease appearing. At Ulm there was only one small epi- demic in seventeen years. At Tuttlingen scarlet fever had not been seen for thirty -five years previous to the epidemic of 1862-63. A number of writers, however, have observed an epidemic cycle in scarlet fever. Thus Fleischmann, 3 at St. Joseph's Hospital, in Vienna, ob- served one of four years. In Dresden, according to Ger- hart, there is an epidemic cycle of from four to five years ; in Munich, according to Ranke, one of three years. On the other hand, scarlet fever often prevails sporadically for a long time in a locality, finally to disappear or to spread suddenly far and wide. Mayr 4 states that in Vienna the register shows that scarlatina has never absolutely died out in fifty years. Scarlet fever is remarkable in the varying intensity of cases occurring during a given epi- demic, and in the differing severity of epidemics. At one time it was regarded as an insignificant disorder, al- most never proving perilous to life. Even now epidem- ics of an exceedingly mild type are frequent. Graves has told how, between 1800 and 1834, whenever scarlet fever prevailed in Dublin, it was so uniformly mild that medical men attributed the bad results of their predeces- sors to improper methods of treatment, and flattered themselves upon their superior skill, until a change in type brought their death rate quite up to that of former times. Etiology.— There is presumptive evidence that scar- latina is due to a specific micro-organism, but the direct and positive proof is so far lacking. Authorities admit 46 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Scarlet Fever. Scarlet Fever, the constant presence of the streptococcus, which may be the direct cause of the inflammatory lesions of the mouth and pharynx, cervical lymph nodes, and probably of the secondary complications, as the heart, kidneys, and other tissues. It is possible that a streptococcus is the specific organism. With the streptococcus, the staphylococcus pyogenes aureus and the pneumococcus are frequently associated. In the light of our present knowledge it is impossible to state whether the toxins which undoubt- edly are present are due to the activity of these secondary organisms or to some specific cause. Class, 16 in a recent paper on the subject, has described a diplococcus, discovered by him, which he believes to be the primary infectious cause of scarlatina. He finds it invariably present in the throat secretions, blood, and scales. He differentiates it from the other micro-organ- isms because it produces in the pig a disease closely re- sembling scarlatina, because the blood of patients conva- lescent from scarlet fever inhibits the growth of the organism, and because it produces nephritis in guinea- pigs. He also shows that a guinea-pig injected with the blood of a patient convalescent from scarlatina may be protected from the pathogenic action of his diplococcus. The coccus in question closely resembles the staphylo- coccus albus. It is very sensitive to environment and at times is so modified in form as to appear as a diplococcus, a streptococcus, or a streptobacillus, the three forms sometimes being present in the same culture. Its size varies from that of a small point just to be distinguished by a one-twelfth oil-immersion lens to a coccus one-third of the diameter of a red blood corpuscle, as seen in old cultures. For routine work cultures are made in the same way as in diphtheria. It is impossible at present to state the importance of this organism in the diagnosis of scarlatina. The results of animal experimentation are not, however, conclusive. Recent bacteriological investigations by Pearce 80 and others have not added materially to our knowledge of the specific primary cause of the disease. While we may assume tne exciting cause of the disease to be an as yet undetermined germ, in the presence of which alone scar- latina is possible, the question of the predisposing causes is a much wider one and demands careful consideration. Predisposing Conditions.— There is a widespread im- pression that scarlet fever prevails more especially dur- ing the fall and winter months. There is, indeed, some difference in favor of these seasons, but by no means to the extent that is generally supposed. Hirsch has tabu- lated the records of 435 epidemics. These prevailed 178 times in the winter, 157 times in spring, 173 times in summer, and 213 times in autumn. The same relative prevalence is shown in his tables of deaths from scarla- tina. Of more than 55,000 deaths from scarlet fever in London, from 1838 to 1853, 32. 1 per cent, occurred in autumn, 25.2 per cent, in summer, 24.6 per cent, in win- ter, 22.1 per cent, in spring. These figures, however, cannot be accepted with perfect confidence, as they must have been influenced by the mildness or severity of the several epidemics. Hirsch's data show also the season of prevalence and the severity of type for two hundred and sixty-five epidemics. n ,rm„-t „ -^ <„„ 1 43.2 per cent, were mild. Of 77 winter epidemics j 55 8 £ er cent _ were gevere , „_.-,,.. . 54.0 per cent, were mild. Of 50 spring epidemics ] m0 £ er cent were severe . , x . „„ .. . i 45.5 per cent, were mild. Of 66 summer epidemics 1 54.0 per cent, were severe. _. ,-„ , ... 1 48.6 per cent, were mild. Of , 2 autumn epidemics j 51 .4 per cent, were severe. The maxima of malignancy fall in winter and summer ; but, as Hirsch remarks, the difference is unimportant. It may be concluded, however, that in the spring epi- demics are usually less frequent and milder. Scarlet fever is chiefly observed in young persons, be- cause older people are generally protected by a former attack. Nevertheless, adults who have never had scarlet fever are less liable to take it than children similarly cir- cumstanced. This is not attributable to differences of age, but to feeble individual susceptibility, which prob- ably held as well during the childhood of these persons. The greatest susceptibility appears to exist between the ages of three and six years. Nearly four-fifths of all cases occur in the first ten years of life. In McCollom's table of 1,000 cases of scarlet fever treated in the conta- gious wards of the Boston City Hospital," 50 per cent. of all cases occurred between two and six years, 78 per cent, in the first ten years, and 90 per cent, before the age of twenty years. It is certain that a not very small percentage of persons successfully resist exposure to the scarlet-fever contagion throughout life. In the epidemic at Thorshavn, Faroe Islands, in 1873-75, from a total population of 930 inhabitants, comprising all ages and not protected by a previous attack against scarlatina, only 38.3 per cent, was infected by scarlet fever. Holt is authority for the statement that not more than one- half of the children exposed take the disease. While, then, it is not difficult to understand why adults seldom take scarlet fever, it is more difficult to account for feeble predisposition observed during the early months of life. Infants less than a year old are rarely attacked, and often escape even when exposed directly and frequently. They do not, however, possess absolute immunity ; in- deed, scarlatina during foetal life has been reported. Leale observed such a case, as did also Tourtual. Thomas records several cases occurring in the practice of others. Veit noted scarlet fever in a child fourteen days of age. Numerous similar observations, more or less trustworthy, have been recorded. On the other hand, Murchison saw two new-born infants remain healthy while their mothers suffered from scarlet fever. New-born children are so subject to cutaneous and other disorders that may read- ily be mistaken for scarlatina, that we may well demand the most definite testimony. Scientific exactness should require that a new-born child must be proven either to have served as the medium of contagion for others, or to have developed characteristic symptoms in the midst of predisposing surroundings. Both sexes are equally sus- ceptible to infection. The predisposition to scarlet fever is much less univer- sal than that to measles and smallpox. While the two latter diseases will almost certainly attack all unpro- tected persons exposed to their contagion, scarlet fever often leaves unscathed persons who have been brought into the most intimate personal relations with it. In the epidemic at Thorshavn referred to above, only 38.3 per cent, of the total population proved to be susceptible to scarlatina, whereas in the same population in an epi- demic of measles in 1875, 99 per cent, of those not pro- tected by a previous attack was shown to be susceptible to measles. It is consequently much' easier to practise isolation with the hope of success. However, the im- munity possessed by an individual, as shown by repeated exposures, may not prove perpetual, and well-marked, even fatal, scarlatina may follow a final exposure. A degree of immunity from scarlatina is sometimes exhib- ited in families, the members of which escape altogether, or have only light attacks. Unfortunately, on the other hand, a decided family predisposition to the disease is occasionally encountered, one member after another fall- ing a victim to its virulence. Careful observation has failed to show that predisposi- tion to scarlet fever is especially favored by the nature of the soil or the state of the weather ; neither can it be proven that the type of the disease is especially influenced by any ordinary surroundings, further than that condi- tions of life prejudicial to the maintenance of good health diminish the powers of resistance to the onset of the dis- ease. It is important to remember that in the absence of the contagious principle no degree of filth, deprivation, dampness, bad ventilation or drainage, or exposure, no matter how injurious to general healthfulness, can serve as the starting-point for scarlet fever. Indeed, it is re- markable, considering the bad hygienic environment of the poorer classes, that between them and the rich there should be so small a difference in the degree of predispo- sition to, and in the relative mortality from, scarlatina. Mode of Infection. — To develop scarlatina an individual 47 Scarlet Fever. Scarlet Fever. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. must, of necessity, receive into his body the materies morbi derived from one who has, or who has had, the disease. In all cases the contagion must be communi- cated by the air, or in solids or fluids received into the body. It is probable that physical contact occurs but rarely between infected and unprotected persons, and that when it does occur, the danger of infection is due rather to the increased liability of intercepting emana- tions from the body. Scarlet fever appears to be not contagious at the very beginning. In this respect it dif- fers markedly from smallpox and measles. In the pro- dromal stage the contagion is probably not set free as readily as at a later period. Girard, however, has as- serted that it is contagious only on the first day. This hardly needs a refutation. Longhurst 6 also claims that it is most contagious during the pre-eruptive stage, and not at all during desquamation. These and similar opin- ions of individuals are negatived by the almost universal experience of observers. Scarlet fever develops its high- est properties of contagion during its period of eruption, and, still unlike measles, retains its contagiousness until desquamation is far advanced. Two children, at the Netherfields Institution at Liverpool, were believed to have been centres of contagion six and a half weeks af- ter the beginning of their illness. 6 Cameron' reports a case in which, nearly nine weeks after the beginning of her own attack, a child communicated the disease to her sister by contact. It seems probable that the power of communicating scarlet fever is retained, gradually di- minishing in intensity, until the end of desquamation, which may not be completed for six, eight, even ten weeks. Thomas mentions cases in which children, even after the completion of desquamation, while suffering from scarlatinal dropsy, probably served as centres of contagion. The agency of the atmosphere as a contagion- hearer does not seem to extend beyond a few yards. Thus, it often happens that the disease does not spread beyond the sick-room, provided mediate contact can be avoided. Possibly the contagion is of too great gravity to be wafted for any distance. Yet it is certainly, under certain conditions, very tenacious of life, and may be conveyed long distances and preserve its properties for prolonged periods. It has often been carried by a healthy person, who has been exposed to the malady, to persons at a distance. There are authentic accounts of phy- sicians, nurses, attendants, and visitors serving thus to carry infection. Such unfortunate occurrences are not very common, and pi - obably happen only when the car- rier of contagion passes directly from the sick-bed to the unprotected person, without due regard to the proper disinfection of the person and clothing. A pernicious custom is the habit of putting on over-clothing and wraps over the dress in which the patient has been visited with- out proper exposure to the free circulation of fresh air. The tenacity with which the contagion clings to inani- mate substances is most remarkable. Articles of cloth- ing, bed-linen, furniture, wall-paper, hangings, and the like, frequently serve to communicate the disease, and often after almost incredibly long intervals. Richard- son gives an example of this. Four children lived with their parents in a thatched cottage. One child was taken with scarlet fever, and the others were sent away. After three weeks one of these was permitted to return. It took the disease on the first day and died. The walls of the cottage were now cleaned and whitewashed ; every- thing was thoroughly scrubbed, and all wearing apparel was washed or destroyed. After four months another child returned. The next day he was seized with the disease and died. Here the thatch was thought to have retained the contagion. The germs of the disease may be shut up in a letter and conveyed a long distance. Woollen clothing, put away and brought out after many months, pillows, cushions, toys, books, have all been known to preserve the contagion in full vigor. The dis- semination of the virus in the atmosphere has been stated to be very limited, but the same cannot be said so confi- dently concerning the agency of fluids. The spread of scarlet fever has never been directly traced to the water- 4S supply, but there is abundant reason to attribute its occasional extension to the medium of milk. Thomas quotes two examples of this. One, reported by Bell, leaves it an open question whether the milk, its recepta- cle, or the boy who carried it, was the medium. The other came under the observation of Taylor, who noticed " that one of the first severe cases which initiated an epi- demic occurred in the house of a milkman whose wife milked the cows, the milk being supplied to about twelve families in the city. In six of these scarlatina occurred in rapid succession, at a time when the disease was not epidemic, and without any communication having taken place between those who were affected and the person who brought the milk. It is very probable that in this instance the milk was the carrier of the contagion, as, previous to its distribution, it had stood in a kitchen which had been used as a hospital for scarlatina pa- tients." More recently, Airy, in eighteen families, con- sisting of thirty-five persons, reported twenty-four of these sick with scarlatina within thirty-six hours. Every one of these patients received milk from the same source. Neighbors who had milk from other sources were not attacked. It was found that a person who milked the cows lived with a child in full desquamation from scar- latina. Several observations of this kind make it hardly doubtful that milk may serve as the vehicle for the scar- latina virus, and that it, indeed, may be considered a fa- vorable culture -fluid for it. But until recently it has not appeared that the virus-bearing milk received its contam- ination otherwise than through human sources. Later investigations seem to throw much light upon the possi- ble origin of scarlatina in man, and upon one of the paths for its dissemination previously unrecognized. An out- break of scarlatina among persons who received their milk supply from a dairy in Hendon, in England, in 1885, seemed to be traceable directly to a disease of the cow. The cows of this farm were affected with a pecul- iar affection, among the symptoms of which were a shedding of the hair and the formation of vesicles and ulcers upon the teats and udders. The nature of the dis- ease in this case is, however, doubtful. Crookshank held that it was cowpox and had nothing to do with scarlet fever. In 1900, Kober 81 collected records of 99 epi- demics of scarlet fever, and of these there was scarlet fever at the farm or dairy in 68 ; in 17, employees them- selves were infected, and in 10 they acted as nurses ; in 6, persons connected with the dairy either lodged in or had visited infected houses ; in 2, infection was brought by cans or bottles from the houses of patients suffering from scarlet fever ; in 3, the milk was stored near or in the sick-room ; in 1 case milk utensils were wiped with an infected cloth. The existence of scarlet fever in animals has been claimed by such authorities as Salmon and Peters; other writers maintain that the disease is not identical with scarlatina as seen in man. In this connec- tion it is an important fact that inoculation of cows, es- pecially when in milk, with the virus of scarlatina, re- sults in the production of definite symptoms. The scarlatinal virus gains access to the blood through the respiratory tract, and is also conveyed in solid and liquid food to the stomach, whence it is absorbed. Though it is unlikely that absorption can occur through the sound skin, the disease is said to have been inoculated by artificial deposition of contagion-bearing material upon the abraded cutis. Miguel d'Amobise claimed to have inoculated children successfully with blood taken from scarlatinous patches. Stoel and Harwood have been reported as having conducted successful inocula- tions. On the other hand, Petit-Radel failed in his experiments. New observations upon this point are re- quired. The contagion probably resides in the epidermis, and becomes diffused as this is exfoliated; also in the buccal and faucial mucous membranes, and probably in the secretions, in the lymph, and in the blood. In the absence of reliable inoculation experiments we have no fixed knowledge upon these points. Incubation. — Scarlet fever has a shorter and much less definite period of incubation than the other eruptive REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Scarlet Fever. Scarlet Fever. fevers. In determining the interval between infection and the outbreak of symptoms, it is much easier to reach correct conclusions when the fever has followed a single exposure than when the exposures have been repeated or prolonged.- There is abundant evidence to show that the period of incubation may bo less than twenty -four hours. On the other hand, it has been claimed that four or five weeks may elapse before the disease manifests it- self. Most cases of scarlatina have an incubation period of from four to seven days. Even this wide limit, differ- ing markedly from that of the other eruptive fevers, is subject to very many exceptions, and the literature teems with examples of scarlet fever developing a few hours after exposure, or only after many days, even weeks. Murchison believed the incubation period to be more often less than forty-eight hours in duration. The shortest authentic stage of incubation was in the case of Richardson, who after auscultating a scarlet-fever patient immediately became nauseated and chilly. He was con- veyed home in the carriage of a friend, and dated an at- tack of scarlatina from that hour. Incubative periods of not more than twenty -four hours have been reported by many writers. 8 In 20 cases Dukes found the duration to vary from one to nine days, in 10 cases it was less than five days. Murchison reported, in the Transactions of the Clinical Society, 9 the incubative periods of 75 cases, none of which exceeded ten days. He considered a per- son safe from contagion who is not attacked within a week after exposure. Thomas 10 thinks that, from four to seven days is the most frequent interval; Kaposi con- siders it to be about eight days; Gee thinks that seven days are rarely exceeded ; Lewis Smith, that it is ordi- narily less than six days. Longer intervals, however, are not infrequently noted. In one case, Hagenbach" de- termined it to be eleven days; in another, fourteen days. Intervals of twelve days or more have been recorded by Veit, Paasch, Boning, Lewis Smith, and others. From the rather untrustworthy results of inoculation, seven days would seem to have been the incubative period. Barthez and Rilliet, Gee, and others thought they had ob- served cases in which the incubative period covered sev- eral weeks, and, indeed, in delicate children, especially those with rachitis or with one of the neuroses, it may be much prolonged (Mayr). Holt 18 has collected 113 cases scattered through medical literature, occurring under circumstances which made it possible to determine the exact length of the incubation. The periods of incu- bation in these cases were as follows : Gases. Twenty-four hours or less. . . 6 Two days 15 Three days 28 Four days 25 Five days 6 Six days 15 Seven days 8 Eight days 2 Nine days 5 Eleven days 1 Fourteen days 1 Twenty-one days 1 Total 113 There is a growing belief that the incubation of scarlet fever lasts less than six days, and, without attempting to be more accurate, we accept that as the common dura- tion. It is very often less than this, and but very seldom more. In this, as in most other features, scarlet fever shows great variability, and, if the term be allowable, a capriciousness contrasting strongly with the behavior of other specific fevers. Symptoms: Period of Invasion. — For convenience of de- scription it will be proper to describe scarlatina as fol- lowing an ordinary or mild, and a graver, course. The course is very often irregular, from the absence of char- acteristic symptoms, or from the undue prominence of one or several of them, or from the presence of complica- tions. In fact, scarlet fever may vary from an insignifi- cant, even an unappreciable, disturbance of health, to a malady pursuing its fatal course with lightning-like ra- pidity ; and although the type of the prevailing epidemic may be mild, severe, or malignant, individual cases can only in a measure conform to the standard, from which they will invariably differ to a greater or less extent. Milder Forms. — At the end of incubation the active Vor,. VII.— 4 symptoms of scarlet fever usually develop suddenly; rarely they appear more gradually. In most cases fever is the first symptom observed. In larger children and adults an initiatory chill is often noted. Convulsions may occur at the outset ; usually, however, they usher in graver forms of the affection. The fever develops dur- ing the night, or during the day the child loses its play- fulness and in a few hours is found to have a high tem- perature, in most cases not exceeding 103° F. (39.5° C), but occasionally reaching 104° to 105° F. (40° to 40.8° O). At the same time the pulse will be full and fre- quent, beating from 120 to 140 times in the minute very commonly. The rapidly rising temperature and great acceleration of pulse are characteristic, and under favor- ing conditions should excite suspicions of scarlatina. The face becomes flushed, the eyes bright and injected. There is much thirst, but almost complete anorexia. Nausea and vomiting are so frequent that J. Lewis Smith attaches some diagnostic importance to the symptom. Of 214 patients it was present in 162. Jenner thought that severe vomiting is apt to precede severe throat symptoms. Diarrhoea sometimes occurs, especially in graver cases. The tongue may be only slightly coated; frequently it is covered with a white, creamy fur, but remains red at the edges. Already the little patient complains of sore throat (indeed this may be the first symptom to attract attention), and upon inspection the mucous membrane of the pharynx will be found to be swollen and dry, and of a bright or dusky -red hue, and often spotted with small areas of duskier redness. At this stage no curdy nor diphtheritic deposit will be ob- served. The nasal mucous membrane sometimes partici- pates in the hyperemia, and a nasal catarrh is induced. There will now be difficulty in deglutition, and already there may be some enlargement of the submaxillary and cervical lymph nodes. There are often headache and also delirium, sometimes of an active kind. As the fever increases in severity the patient becomes dull, listless, and drowsy, and various symptoms of cerebral disorder are common in graver cases. In very many cases, however, all the symptoms will be mild. There may be little fever, no noticeable disturbance of the various functions, not even sore throat. Beyond slight peevishness and irrita- bility the child may not seem to be unwell. In not a few cases there may be no prodromal period at all, the erup- tion first attracting notice. During the prodromal stage the urine is rather scanty, acid, and high-colored. Ac- cording to Gee, the urine is diminished in quantity ; urea is not necessarily increased ; chloride of sodium is dimin- ished, sometimes decidedly, the diminution generally ceasing suddenly on the fourth, fifth, or sixth day ; phos- phoric acid, at first- normal, is notably diminished on the fourth or fifth day, remaining for four days from one- third to one-half the normal quantity, and then returning to the healthy standard ; uric acid is greatly diminished on the second and third days, becoming excessive on the fifth day, and then normal. Even at the earliest obser- vation albuminuria may be noted. BOning, who denies a prodromal stage, and always encounters the erup- tion on the first day simultaneously with the chill, has found blood corpuscles, renal epithelium, and albumin in the urine from the very start. The respiratory move- ments quicken in proportion to the rapidity of the pulse. Nearly all cases will begin to show the eruption within twenty -four hours, many within twelve hours, a few dur- ing the second day. When the eruption appears later, an abnormal or unusually severe form of the disease often follows. Stage of Eruption. — The eruption first appears upon the sides of the face, upon the neck and submaxillary region, and on the front of the chest, in the clavicular region, as small, pale-red points, closely aggregated, al- though at first discrete, and very slightly ele.vated. It rapidly extends over the chest (where it becomes most intense), and over the upper and lower extremities, and attains its full distribution by the end of the second day, acquiring a bright red or scarlet color. It occasionally happens that the eruption begins on other parts than 49 Scarlet Fever. Scarlet Fever. REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. those mentioned, or may never become general. Rarely it spreads more slowly, even fading in some localities before the lower extremities are invaded. It is especially apt to affect the flexures of the joints. In mild cases the spots remain discrete over most of the body, and may resemble a fine " prickly heat, " densely arranged and of minute size. At times the eruption consists of dark-red points, sur- rounding hair follicles, separated from each other by less intensely red areas (Henoch). In cases of greater intens- ity it is coalescent almost universally, and presents a con- tinuous brilliant scarlet surface, like the shell of a boiled crab or lobster. The intensity of coloration varies some- what, even in the same patient, depending much upon the degree of heat ; becoming paler when the surface is cooled, more scarlet when this is protected by heavy covering, etc. It is, however, not perfectly smooth, but shows the tiny papules upon the reddened base, and communicates to the hand passed over it a sensation of roughness and of dry and pungent heat. Upon the legs and arms the eruption very often becomes more scat- tered, assuming the form of separate tiny points ; rarely it is distributed over distinct areas of the trunk and ex- tremities, with intervals of faintly erythematous redness (scarlatina variegata). This form, however, is apt to appear in severe complicated cases. At the same time it must be remembered that, unlike measles, scarlet fever af- fects the face less than other parts. Never very intensely developed over the forehead, temples, or chin, the erup- tion entirely spares an area around the mouth, including the upper and lower lips and some distance beyond the angles of the mouth, and often extending upward to in- clude the nose. This area contrasts with the surrounding parts by its remarkable pallor. It has been asserted that the cheeks are also spared by the eruption. This is not true. The cheeks do not show the pointed redness of the early eruption elsewhere, but at once assume a scarlet or crimson redness that is deeper than the color induced by fever. The lips are often dry and cracked, and may bleed . The face becomes considerably swollen, especially in the loose tissue about the orbits. The ears are also swollen and of a bright red color. The eruption does not spare the scalp. Upon the backs of the hands and feet the eruption is discrete, and is arranged in groups the size of a lentil, while upon the palmar surfaces of the hands and fingers, and upon the soles of the feet, a bright, diffused redness, with swelling, is seen. At times the eruption will be partial, developing upon the trunk alone, or on the extremities, or in isolated patches about the body. These cases may not be abnormal in other respects. The skin over the joints is especially prone to be affected. The lesions may be more or less disseminated spots, vary- ing from the size of a pin head to that of the finger nail, or a half-dollar, or even larger. It has been asserted that the eruption constantly consists of a papulated rash upon a reddened base, even when universally diffused. This is not invariably so, and one may encounter a smooth, uniform redness inappreciable to the touch. Where the eruption is very intense, small hemorrhagic spots or petechiae may appear. When thus occurring; their occasional presence is not of serious importance. In warm weather especially, and in children too warmly covered with bedclothes, the surface, particularly of the neck, chest, and belly, is sometimes plentifully sprinkled with an eruption of sudamina. In some epidemics these are more often observed than in others. It is not impos- sible that the "miliary fevers " that formerty occasionally prevailed in Europe were in reality forms of scarlatina. Mayr has said that the eruption of scarlet fever often spares the skin of paralyzed limbs ; but Kaposi asserts that it may be unusually intense upon these parts. In dark-skinned races the eruption undergoes some modifi- cations, which are greatest in those of full negro blood. In mulattoes and negroes it becomes often exceedingly difficult to distinguish the eruption. Of course the scar- let color is absent, a tinge of red will often struggle through the darkly pigmented skin, especially of the cheeks and abdomen. The true character of the eruption may often be revealed by a finely papular condition, the tiny papules of the size of a pin-point being made ap- parent by their acuminated summits, which give, against the dark background, a resemblance to a sprinkling of the surface with a fine dust. The hand passed over them can perceive the little asperities. These are closely ag- gregated. In many cases it is impossible to recognize the eruption, and the diagnosis must rest upon the con- comitant symptoms, which will not be peculiarly modi- fied. While the eruption — which attains its height by the end of forty-eight hours in mild cases, later in severe ones — is developing, the other symptoms become pro- nounced. The faucial mucous membrane is uniformly redder, or occasionally shows numerous red macules; the uvula, tonsils, and buccal mucous membrane are red- dened and swollen, and pain in deglutition increases. As the eruption reaches its height, the tongue parts with its coating in patches, exposing areas of intense redness. By the third day it acquires a uniformly brilliant red color, with enlarged papillae scattered numerously over its general surface, and presents the characteristic " straw- berry " or " raspberry " appearance. Exceptionally this exfoliation of the lingual epithelium does not occur, and the creamy deposit persists. In many mild cases there is slight nasal catarrh, with a thin discharge from the nos- trils. A muco-purulent discharge from the nostrils is associated with the throat complications of the graver forms. During this period the fever continues to increase until the completion of the eruption, or the prodromal temper- ature remains unchanged. In the type of cases we are considering 105° F. (40.5° C.) is not often exceeded. Should the fever continue to increase after the third day, grave solicitude as to the result will be justifiable. The other symptoms continue with undiminished vigor — di- gestive disorder, nausea, vomiting, complete anorexia, rarely diarrhoea, persist. The skin burns or itches more or less intensely. Nervous symptoms, restlessness, stu- por, headache, delirium, usually diminish, but may con- tinue unabated ; or active delirium may occur. Convul- sions at this time are very ominous. The sore throat becomes distressing, and the cervical and submaxillary glands enlarge and become painful. Bronchial and pul- monary inflammations occur only as complications. After the fourth or fifth day nearly all of these symptoms cease to increase, and it becomes evident, cceteris paribus, that the course of the disease is to be favorable. The erup- tion, after persisting in full development for a day or two, becomes duller and slowly fades, first in the parts earliest affected, latest from the back of the hands. The color, which at first completely faded, now leaves a yel- lowish stain when the finger compresses the skin. It is not, however, until after four, five, or six days, that the skin loses its scarlet color. This may last longer. Jen- ner 12 has known it to persist for from fourteen to sixteen days._ The fever slowly declines, until it "ceases about the sixth, seventh, or eighth day, or later, and not before the eruption has entirely disappeared. Sometimes, from unknown reasons, it persists for days after all local symp- toms have ceased to be active. On the other hand, fever, in some very mild cases, will hardly be noticed, or will endure but a few hours. The throat manifestations, or the supervention of complications, may protract the fe- ver for many days. The sore throat, unlike the other symptoms, often fails to show signs of amelioration after the height of the eruption. The swelling and redness may increase, and white or yellowish curdy deposits form upon the tonsils and uvula, or the posterior wall of the pharynx may be bathed in a thick muco-purulent dis- charge from the posterior nares. True diphtheritic mem- brane is not apt to form in these cases, but the neigh- boring lymph nodes may become highly inflamed and suppurate. It is probable that renal catarrh and nephri- tis occur more frequently during this period than is com- monly supposed. The character of the urine is subject to considerable variation. At the beginning of the dis- ease it has the appearance of the ordinary febrile urine or of a severe active hyperaBmia. It is not usual for an 50 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Scarlet Fever. Scarlet Fever. acute nephritis to develop in the early stages of scarlet fever, but is most common in the second or third week. It may develop after the mildest forms of infection, and the greatest care should be (even when convalescence is well advanced) to guard against this serious complica- tion. Frerichs, Reinhardt, Eisenschitz, Boning, Begbie, Newbigging, Holder, and others, consider the renal symptoms to be essential in scarlatina. This is, however, not true. Thomas 13 practised microscopic examinations of the urine in twenty-five of eighty patients, and in twenty of these daily. In the prodromal and eruptive stages he found slight albuminuria only rarely and tran- sitorily. Decided alterations in the renal tract were most uncommon. Mild catarrh was more often seen. Only the more severe forms he considered to depend upon a specific scarlatinal influence. Fleischmann, ' 4 i n 472 cases of scarlatina, reported dropsy during the first week in 9 cases. Not enough, certainly, to bear out the sweeping assertions just quoted, but sufficient to direct attention constantly to the condition of the kidneys in scarlatina. Many cases of mild scarlatina fail to exhibit all the symptoms enumerated. The prodromal stage may be absent, sore throat may be insignificant or absent through- out. The tongue may never assume the " strawberry " appearance. The fever may be of feeble intensity. Fi- nally, the rash may be faint and not widely distributed. It may be limited to a few reddish or pinkish punctate spots upon the neck or chest; or it may affect only the flanks or the flexures of the joints ; or it may be so transi- tory as to escape observation or to be noted only during a few hours ; or, finally, it may fail altogether to appear. On the other hand, sore throat may be the only active evidence of the disease. Cases that have been exposed to the contagion sometimes develop sore throat only. These may subsequently become dropsical from nephri- tis, or they may desquamate more or less abundantly, or even communicate scarlet fever to others. An interest- ing feature is a tendency, often shown >by those exposed to contagion, to suffer from a mild attack of pharyngitis after every exposure. Many physicians, nurses, etc., experience this. Finally, the eruption may fail to ap- pear, knowledge that scarlatina was present being ac- quired through the occurrence of desquamation or dropsy. Cases of this kind have been designated "scarlatina sine exanthemate." They are not so very rare. At other times the eruption is so indeterminate in appearance that, in the absence of accompanying symptoms, it is impos- sible to speak positively of its character. Stage of Desquamation. — After the fading of the erup- tion the patient passes into the stage of desquamation. This is an immediate result of the eruption. Desquama- tion begins usually upon the neck, and continues for from eight to fourteen days, but not infrequently for four, six, or even eight weeks or more. Usually not earlier than the sixth day of the disease it is noticed upon the neck and face, and quickly extends over the whole surface, and may even occur upon parts not visited by the eruption. Upon the face and neck the scales are mostly fine, but coarser than those following measles. From other parts the epidermis peels in great shreds. On the hands and feet the lamella? are always large, and sometimes from these members the cuticle is removed in masses resembling a glove or slipper. Desquamation en- dures longest where the epidermis is thickest, often for weeks; that newly formed exfoliating repeatedly. The hair and nails are sometimes shed after scarlet fever. Desquamation is at times observed in those who have had no eruption, or at least one of very circumscribed extent. With the completion of desquamation the dis- ease may be said to have run its course. Great care, however, must be exercised for some weeks to protect the patient from the effects of complications and from the sequela? to which the disease has made him liable. With the fading of the eruption, the cessation of fever, and the beginning of desquamation, general improvement takes place. The tongue gradually resumes its normal appearance or for a time becomes again coated ; the sore throat diminishes; the various functions are properly performed; appetite and strength return. Desquamation may, however, be sometimes delayed. The local use of oils and ointments during the eruption tends to make the desquamation less free. The occurrence of dropsy, de- pendent upon the development of an acute nephritis, sometimes defers the beginning of desquamation, and this may not become abundant until after the dropsy has subsided. Contagion has spread from desquamation be- ginning in this manner, after isolation has been aban- doned as no longer necessary. In rare cases desquama- tion can hardly be said to occur at all. Even in mild cases, in winter, the patient should not be permitted to leave his bed until the end of the third week, or to leave his chamber until the completion of desquamation. In midsummer it is usually not advisable to insist upon con- finement to bed for so long a period. Cases which run the apparently mild course just described are by no means free from danger, as they are often accompanied or followed by local pathological processes which, while they may not be essential symptoms of scarlet fever, are especially prone to affect those suffering from it. Such lesions will be considered among the complications and sequela? of scarlatina. Graver Forms. — Every case of scarlatina is dangerous. In those following the type just described the peril arises from processes that are not essential to the disease. Such forms pass, by insensible gradations, into those where life is imperilled by the greater or less intensity of char- acteristic phenomena. The graver forms of scarlatina may not differ in their initiatory symptoms from those already described. In most cases the severity of the dis- ease is in great measure dependent upon lesions in the throat, while, as a rule, the eruption shows a more gen- eral distribution and a more intense coloration. The pro- dromal symptoms do not differ in kind from those of milder types, but are more severe. Vomiting is more apt to occur, and nervous symptoms to become prominent. Headache, jactitation, and delirium become more marked, or the patient grows petulant, drowsy, and stupid. Con- vulsions also may occur. Fever attains great intensity at the very outset, reaching 40° to 42° C. (104° to 106° F.), the latter temperature always denoting extreme dan- ger. There is already sore throat, with difficult deglu- tition and with swelling and deep redness of the faucial mucous membrane, which by the third day, in the less severe cases, shows curdy deposits scattered over the tonsils. These deposits do not involve the mucous mem- brane, and may generally be detached by a mop or a brush. They are quite like the exudation of ordinary catarrhal pharyngitis. After the third or fourth day, under conditions of constantly increasing fever and gen- eral distress, in some cases, diphtheritic exudation begins to show itself over the tonsils and soft palate and poste- rior wall of the pharynx. It is an interesting point of difference between primary and scarlatinal diphtheria that the latter never begins to appear before the third or fourth day, after which date it is sufficiently common. Fleischmann reported diphtheria 168 times in 472 obser- vations. The diphtheritic deposit is first developed on the lateral portion of the tonsils, except in those rapidly fatal cases in which the whole pharynx seems to be simul- taneously involved. The patches are of a whitish or grayish-white color, and involve the mucous membrane sometimes to a considerable depth and superficial extent. At times the diphtheritic membrane rapidly spreads in a continuous sheet over the fauces, extending forward into the buccal cavity and into the posterior nares. In the latter case, a fatal termination is almost inevitable. Heubner 14 asserts that those cases in which the entire mucous membrane, from the root of the tongue to the oesophageal and tracheal orifices, is covered with the membrane, prove fatal within twenty-four or forty-eight hours, without exception. Here the membrane is sharply margined against the dusky-red mucous membrane, and within a few hours the slough shows signs of separation and develops a gangrenous odor. In these cases the membrane hardly ever travels down into the trachea. Bretonneau has made a positive assertion that this does 51 Scarlet Fever. Scarlet Fever. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. not occur. It does so occasionally, however. Lewis Smith reports cases, with necroscopic examination, in which diphtheritic membranes extended along the trachea into the bronchial tubes. In the most severe cases, how- ever, the deposit does invade the posterior nares, and the ordinary slight catarrhal discharge is supplanted by an offensive sanio-serous or sanio-purulent discharge from the nostrils, which causes excoriation of the upper lip. _ At the same time the nares become obstructed, and the little patient is driven to breathe almost entirely through the mouth. In many cases of extreme throat involvement the strength rapidly fails, pallor replaces the prematurely receding eruption, except at certain spots where this may persist as circumscribed patches of dusky redness; the temperature remains stationary or falls, the pulse be- comes more and more feeble and rapid, and death ensues within a few hours, as if from blood-poisoning. Death either follows a slow spread of gangrene to the soft palate and tongue behind the sinus pyriformis, and to the walls of the throat, or occurs through diphtheritic inflammation of the lymph nodes and connective tissue of the neck, or through oedema of the glottis. At other times the clinical appearances during the first week may not be alarming, danger becoming imminent about the begin- ning of the second week. The fever may remain ele- vated, the eruption brilliant and intense, until a short while before death. In the rapidly fatal cases the throat and neck may not appear very much swollen. At other times. the neck and submaxillary region are greatly swol- len, principally from the inflammation of the glands and periglandular tissue. These parts become hard and brawny, and from the pressure upon the great veins ac- quire a livid appearance, which may also be communi- cated to the face and head. The tonsils and soft palate may be swollen until the throat will appear quite closed. The mucous membrane will be deeply congested, and covered here and there with diphtheritic exudation and with ulcers caused by the separation of sloughs. The posterior wall of the pharynx may be bathed in muco- pus. Retropharyngeal abscess is sometimes formed, and may precede the fatal termination. Dyspnoea may result from swelling of the fauces caused by inflammatory exudation into the parts, from oedema glottidis, or from extension of diphtheria to the larynx and trachea, or it may be a result of the imperfect oxidation of the blood. The term " diphtheritic " is here used in a clinical sense, to designate a condition of coagulation necrosis in the tissues involved, and has no reference to a pathogenetic relationship with true diphtheria. This necrosis occurs simply as a result of the intensity of the accompanying inflammatory changes. There is no evidence that true diphtheria may not coexist with scarlatina, but that the commonly observed membranous pharyngitis of scarla- tina represents this combination is most improbable. Many of these membranes are undoubtedly due to the action of the streptococcus and staphylococcus infections. Their differentiation from true diphtheria is now made easy by the bacteriological examination in reference to the presence or absence of the Klebs-Loeffler bacillus. J. Lewis Smith has seen four instances in which the diph. theria became dissociated from the scarlatina, and attacked other persons as idiopathic diphtheria. Such observa- tions are exceedingly uncommon. The scarlatinal diph- theritic membrane is indeed essentially identical with that of idiopathic diphtheria in structure. The differences are etiological. The diphtheritic poison and the scarlatinal poison, differing in their specific natures, possess in com- mon the power to excite such violent inflammatory changes in the tissues that a coagulation necrosis results. The diphtheritic membrane of scarlatina, then, is purely scarlatinal in its origin. This view has received solid indorsement. It has been adopted by Henoch. Heub- ner considers scarlatinal diphtheria to differ from primary diphtheria both clinically and histologically. It begins with a simple catarrhal affection, and, following his ob- servations, changes from catarrhal to diphtheritic inflam- mation on the fourth day. Koven also thinks that the throat affections of more severe grade are characterized by necrosis from direct intensity of the scarlatinal process, and are not of a truly diphtheritic nature. He observes that while two acute" diseases rarely coexist, of 426 cases of scarlatina 125 had necrosis faucium, although at the period of observation there was not a single case of pri- mary diphtheria in Christiania. He further declares that diphtheritic paralysis never occurs after scarlatina, and that while true diphtheria shows the membrane at once, the scarlatinal slough usually appears after several days of increasing angina, and does not extend to the larynx. Henoch has never seen a single case of accommodation paralysis of the eye or of the soft palate, nor of the neck, nor of the extremities, after scarlatinal diphtheria. The inflammation may, often docs, extend along the Eusta- chian tube to the middle ear, and excites changes that give scarlet fever one of its principal terrors, resulting often in more or less complete permanent deafness. These changes will be considered with the complications and se- quelae of scarlatina. In a number of these cases cervical adenitis and periadenitis occur, and prolong the fever be- yond the eruptive stage indefinitely, frequently resulting in suppuration. Occasionally the pus burrows deeply among the tissues of the neck, and extensive gangrene may follow. Williams has reported a case of extensive sloughing in the left anterior triangle of the neck, with exposure of vessels, followed by recovery. Other similar cases have been recorded. In most cases in which death does not speedily occur after suppuration and evacua- tion of pus recovery will take place, but the patient may ultimately succumb under blood-poisoning and protracted fever. Occasionally, also, parenchymatous tonsillitis may cause rapid and enormous enlargement of the tonsil, with the formation of pus, a condition of extreme grav- ity, especially if associated with retropharyngeal abscess and oedema of the glottis. In favorable cases the sloughs in the fauces will cease to extend, the oedema and dusky redness will slowly subside, and the diphtheritic ulcers begin to granulate. In many cases the faucial symptoms here described do not appear, only because life is early destroyed by the intensity of the action of the specific poison upon the blood and tissues. In such malignant cases the patients often die with the rapidity of those who succumb to narr cotic poisoning ; or a series of convulsions inaugurate the disease and terminate life within an hour or two. This has been called the atactic form of scarlet fever. At other times brief initiatory symptoms have been followed by intense fever (106°-109° F.), with uncontrollable vom- iting, diarrhoea, delirium, rapidly deepening coma, and death, before the appearance of the eruption. Or, again, the disease may begin in the ordinary manner, not sug- gestive of a severe course, and alarming symptoms may not develop until after several days ; or it may be intense from the beginning, with severe and repeated convul- sions, vomiting, profound nervous depression, and the appearance of the eruption at the usual time, with stead- ily increasing gravity of all the symptoms, until, after a few days, death results from convulsions or coma. Fi- nally, the malignant symptoms will appear suddenly in the midst of what has seemed a mild attack of scarla- tina. An unusually protracted period of invasion is sometimes the forerunner of malignant scarlet fever, and should always be regarded with apprehension. Cases may at times exhibit at the beginning alarming symp- toms. A decided apathy, in which no notice of what is passing is taken, with great apparent depression and even delirium, excites the apprehension of the attend- ants, yet the pulse and temperature will not show marked variation from the normal. After the second or third day such cases will very often pursue a mild course. A high temperature and very quick pulse may even be added to these symptoms and justly excite alarm, and yet the case may assume a favorable character after the development of the eruption. In such cases as these the probability of the issue in life or death seems to vary from hour to hour. All the symptoms show intensity. The fever, accompanied by more or less severe initiatory symptoms, rapidly increases, the eruption is copious and 52 REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. Scarlet Fever. Scarlet Fever. deeply colored, the pulse beats 130, 140, 160 times, or oftener, to the minute, the respiration is proportionally accelerated, the throat duly shows more or less exten- sively the peculiar alterations. This course may be held throughout the first week, and even longer, without mitigation, the result remaining doubtful all the while. In malignant scarlet fever the usual course is one of intensified general symptoms. Those of the invasion period are indicative of grave perturbation of the econ- omy. By the time the eruption appears it is already evi- dent that the patient is dangerously ill. He is apathetic, or perhaps extremely restless, remaining in one position not an instant. The skin is hot, dry, and pungent, the temperature very high, the features are swollen, the con- junctivae injected, the fauces reddened and dry, the thirst is intense, but water and all ingesta are often vomited as soon as swallowed; the urine is scanty, or even sup- pressed, from acute renal inflammation. Diarrhoea may be present. The nervous phenomena become intensified . The eruption now appears, and may at first develop regu- larly, but after a while will become duskier and will not completely fade on pressure. The color tardily returns to the part whence it has been pressed. Coma or con- vulsions may now carry off the patient in full eruption. Often, however, the eruption will recede from certain parts in whole or partially, or it may become paler uni- versally ; or in place of the regular eruption hemorrhagic exudation will appear. Ecchymoses, from the size of a pinhead to that of the palm, or larger, will replace the usual eruption, which will in great measure disappear. Then livid spots, not fading on pressure, are found, gen- erally upon the flanks and back, but may appear any- where. According to Mayr, the hemorrhagic eruption may appear over a large part of the surface in children, but in adults is mostly confined to the neck, upper part of the chest, the back, and about the joints of the upper and lower extremities. This hemorrhagic variety is the most formidable form of scarlet fever, and is probably always fatal. Hemorrhages from mucous surfaces are exceedingly uncommon. Mayr has described a scarlatinal : dissolution of the blood, in the gravest form of which death occurs in from twelve hours to five days. "Ex- treme muscular depression, with slight headache and a remarkably rapid pulse, are present from the very com- mencement. . . . The patient lies on his back with his eyes half open, but in an unconscious state. . . . Quiv- ering movements of the muscles of the face and of the fingers are also commonly observed in these cases, and in children general convulsions often occur. The pupils are moderately dilated ; the lips and tongue are dry, the latter being usually of a bright-red color. As the dis- ease goes on, mucous rales are heard in the large bron- chial tubes ; the abdomen becomes distended, but there is seldom any enlargement of the spleen ; the urine be- comes scanty and of a dark-red color; the pulse continu- ally increases in frequency, reaching as many as 200 beats a minute ; the features become shrunken and the extrem- ities cold." Death speedily follows. This form resem- bles the so-called typhoid scarlatina, in which drowsiness, stupor, delirium, and subsultus precede the fatal issue. The life-destroying symptoms are often connected with impairment of the heart's action, attributable to crippling of the vagus, when death occurs from heart paralysis, without widespread molecular disintegration. This fail- ure is shown by increasing weakness, frequency and in- equality of the pulse, with quickened and shallow breath- ing, and coldness of the hands and feet. Allbutt has classified the modes of death in scarlet fever as follows : (1) hyperpyrexia (this Jenner denies positively) ; (2) spe- cific blood-poisoning ; (3) special malignity of the case ; (4) asthenia. In the rather uncommon event of recovery from any of the most severe forms of scarlet fever, the progress is slow, the essential symptoms, complications, and sequelse proving all very obstinate. In those cases in which extensive diphtheritic exudation precedes arap- idly fatal course, the eruption undergoes many modifica- tions, the integument remaining pale except for some few splotches about the joints, at other times showing only a few dark-red patches irregularly distributed, and again entirely disappearing before death. At other times the eruption persists in full efflorescence. Clianges in the Mood. — The number of the red corpus- cles in general is but slightly altered, more, however, in scarlet fever than in measles. The same may be said concerning the character of the red cells and the amount of haemoglobin; in scarlet fever poikilocytes and normo- blasts are occasionally found. The state of the leuco- cytes is much more characteristic. In measles there is either a normal number or a diminution of leucocytes ; in scarlet fever there is hyperleucocy tosis. In the former, as the temperature falls the leucocytes gradually increase ; in the latter the temperature and leucocyte curve run parallel. In both diseases, but especially in measles, is the number of polynuclear neutrophilic cells diminished, while lymphocytes, both large and small, are relatively increased. The eosinophilic cells are diminished in num- ber in measles, reaching their normal state long after re- covery ; in scarlet fever they are constantly increased. Complications. — Nephritis. — Derangements of the kidneys are the most important complications of scarlet fever. Indeed, a number of recent writers assert that these organs are always affected in this disorder. Among these may be mentioned Frerichs, Reinhardt, Begbie, New bigging, Holder, Boning, and Stevenson Thompson. Steiner states that evidences of kidney disorder are al- ways present in those who die of scarlet fever. Thomas' clinical observations do not bear out this statement, and Friedlander, who examined the bodies of two hundred and twenty-nine persons dead of scarlatina, found kidney disorder in less than one-half. Though renal inflamma- tion is not shown as yet to be a constant accompaniment of scarlet fever, it occurs much more often than is com- monly supposed. Renal catarrh, which Eisenschitz de- clares to be as much a feature of scarlet fever as bronchial catarrh is of measles, is indeed an extremely common complication. It usually escapes detection from the gen- eral neglect duly to examine the urine. Thomas, in de- nying that this catarrh is at all constant, shows that it also occurs in measles, croupous pneumonia, etc., and is often only an expression of the febrile condition. Yet the catarrh is relatively so common in scarlatina that he cannot avoid concluding that the specific influence of the disease is often concerned in its production. In many cases, from the very beginning, cylinder-like masses of renal epithelium may be detected. In milder cases the urine will contain mucous casts with increased quantity of mucus, but no albumin. In more severe cases the urinary sediment will contain hyaline masses with epi- thelium and epithelial debris, and red and white blood corpuscles. Slight albuminuria will also be present. This catarrh is usually insignificant, and but rarely serves as the starting-point for the graver and characteristic forms of nephritis scarlatinosa, though doubtless many milder forms of nephritis and dropsy originate in it. Thomas concluded, however, that the cases of scarlatinal nephritis not developing from preceding catarrh, but arising suddenly, usually end fatally. Scarlatinal ne- phritis varies greatly in the relative frequency of its occurrence, involving from five to seventy per cent, of cases in different epidemics. In the Children's Hospital, Hillier noted its occurrence in about half of the cases. Dickinson 16 considered this rather below than above the average. Fleischmann " noted 95 cases of Bright's dis- ease in 472 observations. During 1861 every third child with scarlatina had dropsy, while in 1862 it affected only one case in ten. Thomas asserts that renal alterations develop in about one-half of all cases of scarlet fever. It has been shown that there are those who assert that the renal alterations are constant. On the other hand, Jac- coud ,8 declares that for fifteen years he has never had a case of nephritis among his scarlet-fever patients, a result that he attributes to his treatment. Albuminuria may appear at any time during the attack of scarlatina, though its most common occurrence is during the second and third weeks. Dropsy should not be taken as marking the beginning of the nephritis, the signs of which may 53 Scarlet Fever. Scarlet Fever. REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. be present in the urine sometimes for days before this oc- curs. In Fleischmann's cases dropsy occurred 9 times during the first week, 30 times during the second week, 23 times during the third week, 20 times during the fourth week, and 5 times after the fourth week. Of 60 cases at the Children's Hospital, 42 began between the end of the first week and the end of the fourth week ; 5 became dropsical during the first week. Nephritis during the first week of scarlatina often escapes detection from the blending of its symptoms with those of the essential disease, and from the attend- ants' neglect to examine the urine. Dropsy will, of course, attract attention, but this does not often occur so early, and may be confounded with the oedema from the exanthem. Rarely, the fatal issue of what was, ap- parently, malignant scarlet fever, may really have resulted from urasmic poisoning due to a fulminating nephritis. The symptoms may be identical. Fever, vomiting, headache, delirium, amblyopia, coma, convul- sions, may have been present. The convulsions are often very irregular. They may be general, partial, or unilat- eral, tonic or clonic. The patient may have them in rapid succession, or may pass into a status epilepticus from which death alone will release him. The urine will be completely or partially suppressed. If secreted it will be of high specific gravity (1.020 to 1.040), dark and smoky in appearance, loaded with albumin, and forming an abundant sediment of hyaline, granular, epithelial, and blood tube casts, with renal epithelium and white and red blood corpuscles in greater or less quantity. If the kidneys become implicated toward the end of the first week, the symptoms may delay the course of what may otherwise appear to be an ordinary case of scarlet fever. Microscopical research will often betray the on- set of the changes in advance of chemical analysis; casts of the renal tubules will be observed, with epithelial de- posits and detritus, before albuminuria is established. This will shortly appear, and in severe cases the nephritic symptoms will obscure those of the scarlatina. There will be no constant relation between the amount of albu- min, the tube casts, and the general detritus, one varie- ty of sedimentary matter being at one time copious, at another scanty. At this time vomiting may appear with returning headache, the appetite will again fail, and pain in the loins may become annoying; the patient may again become dejected and feeble, and his fever may cease to diminish — may even exceed its original inten- sity. At other times no apparent influence will be exerted upon the scarlatina, which will follow its usu- ally mild course until dropsy and albuminuria reveal the state of the kidneys. When the renal disorder de- velops after defervescence, during the second, third, or fourth week, or later, the same series of symptoms may be observed, their severity being in direct ratio with the earliness of their occurrence. Cases developing after the fourth week may be expected to pursue a favorable course. Although it has been asserted that the renal disorder may arise several months after a scarlatinal at- tack, a patient will almost certainly escape it if he pass the sixth week in safety. The symptoms in cases arising during these weeks are not always gradually developed, and some of the most disastrous results of the disease may be encountered, during the second, third, or fourth week, in children apparently convalescing from scarla- tina, and often in full desquamation, who, after indispo- sition for a few hours, with nausea, headache, confusion of ideas or stupor, with return of fever, rapidly pass into coma or convulsions, ending after a short interval in death, before dropsy has developed, but after partial or complete suppression of urine. Scarlatinal nephritis has usually a mild and favorable course. Dropsy is usually the first symptom observed, first appearing in the face and sometimes remaining confined to this locality; at other times becoming general speedily, and giving an appearance of plumpness, but with a wax -like translu- cency of skin. The face, upper and lower extremities, body wall, and prepuce may thus become dropsical. The serous cavities are also implicated, and more or less effusion into the pericardial, pleural, peritoneal, scrotal, and intracranial cavities occurs. (Edema of the lungs and of the glottis may imperil life. Desquamation is often completely arrested upon the supervention of dropsy. The temperature is more commonly but little above the normal (38.3° to 39° 0—101° to 103° F.). The pulse, sometimes feeble and accelerated, will often become remarkably slow and intermittent, and so remain throughout the attack. The child will grow dull and listless, and extremely feeble. Pain in the belly and in the back may at times prove very distressing, or, again, it may be absent. The tongue, having lost the straw- berry aspect of the eruptive stage, will become pale, flabby, and coated. The appetite will fail, and the bowels become sluggish. The urine will rapidly dimin- ish in quantity and may deposit urates abundantly, or may present a smoky and oily appearance, due to the abundant presence of epithelial cells, white and red blood corpuscles, and tube casts. The total amount may now be reduced to a few ounces. The blood corpuscles often form a thick red layer at the bottom of the test tube. This free admixture of blood may amount to pro- nounced hematuria, is generally post-scarlatinal, and, according to Schiitz, occurs most frequently during the third or fourth week. Of itself it adds but little to the gravity of the case. The patient often feels fairly well, and may eat and sleep with comfort. While the pallor and oedema may be very decided, the temperature and pulse may vary but little from the normal, or may show the variations of ordinary nephritis. With the gradual improvement of the general symptoms the hematuria disappears. Heubner has reported a case of nephritis after scarlatina in which haemoglobinuria was present. The urine was brownish-black ; no blood corpuscles were found. Death resulted from asthenia on the fifth day after both albumin and haemoglobin had disappeared from the urine. The amount of albumin in the urine in scarlatinal ne- phritis is usually very great. The urinary sediment is abundant, and is largely composed of tube casts, the hy- aline character predominating ; finely and coarsely gran- ular, epithelial, and blood casts are, however*, numerous. Later, coarse fatty granules stud the casts plentifully. These casts are often almost diffluent, and differ strik- ingly from the firm and sharply outlined ones of more chronic nephritis. Crystalline deposits are scanty, and are mostly of uric acid and urates ; on the other hand, the amorphous urates are often very abundant. The degree of albuminuria present is of less importance than the total quantity of urine secreted, rapid and pro- nounced diminution of this indicating the accumulation of nitrogenous waste in the blood, and consequently the danger of uraemia. According to Glax, a lessening of the proportion of urine secreted to the fluid ingested (2 : 3) not infrequently foreshadows the approach of uraemic symptoms, even though the urine contain no albumin. Whether the temperature remain normal throughout the attack, or whether, after an initial chill, it become ele- vated, and all the symptoms of acute nephritis develop, complete recovery may reasonably be expected if the patient pass safely through the earlier phases of the disorder. But although nephritis may be mild — the dropsy lasting only a few days, and, perhaps, being limited to slight puffiness about the eyes — the disorder does not usually entirely subside in less than a month. It may endure as long as three, four, or even five months; and there is good reason to believe that chronic nephritis in young people may, in rare instances, have had its beginning in antecedent scarlatinal inflammation of the kidneys. Such a result is, however, exceedingly uncommon. The dropsy indicates the degree of renal derangement, except in the most acute cases, and sometimes attains enormous proportions. As the urine increases in quan- tity the albuminuria proportionately diminishes, and the dropsy disappears. The skin, which until now has been dry and inactive, becomes softer, more elastic, and re- sumes its proper functions. The appetite improves the 54 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Scarlet Fever. Scarlet Fever. spirits, strength, and mental activity return, and good health becomes gradually restored. Just as the micro- scope reveals the earliest evidence of renal derangement, so does it continue to expose the results of pathological action after chemical tests fail to do so. Tube casts con- tinue to appear in the urinary sediment, sometimes for weeks after the cessation of albuminuria, the blood casts, epithelial, coarsely granular, and fatty casts gradually giving place to finely granular, hyaline, and mucous ones, -which in turn finally disappear. "When the dis- order terminates fatally, the symptoms will be those of acute nephritis ; suppression of urine may be followed by cerebral disturbance, headache of violent character, during which blindness may occur, with or without dila- tation of the pupil, vomiting, and convulsions, partial or general, coma, and sometimes paralysis ; or the fatal ter- mination may be slowly reached through constantly in- creasing asthenia ; or, what is more frequent, complica- tions may arise which cannot always be definitely ascribed to the nephritis or to the scarlatina itself. Such are inflammations of the pleurae, of the pericardium and en- docardium, the peritoneum, the cerebral meninges, etc. Pneumonia, acute articular rheumatism, or enteritis, may also hasten the fatal issue. Cases are occasionally observed in which dropsy fol- lows scarlatina, but without albuminuria. Indeed, a ten-- dency toward non-albuminuric dropsy after scarlatina has been associated with certain epidemics. Scarlatinal dropsy without albuminuria has been observed by Guer- saut, Rilliet and Barthez, Noirot, Bouchus, Loschner, Duckworth, and others. Quincke 19 tries to explain such cases of non-albuminuric dropsy as not depending upon nephritis, but as a consequence of the scarlatinal irrita- tion exerting some peculiar influence upon the' connective tissue. Cases occur probably in the experience of most practitioners. One should be cautious, however, in de- ciding against a nephritic origin of these dropsies, except where they can be definitely attributed to anosmia and debility. Henoch 20 has asserted that nephritis may occur without albuminuria up to the time of death. He re- ports a case in which anasarca was present for three weeks after scarlatina, without tube casts or albuminuria, until convulsions occurred, death resulting from oedema of the lungs. The necropsy revealed the presence of acute nephritis. He also reports the case of a child, dead on the thirteenth day, of malignant scarlet fever, in whom repeated tests during life had not shown albuminuria, and yet whose kidneys showed indubitable evidence of hemorrhagic nephritis. Steiner has seen nephritis with- out dropsy, but never dropsy without nephritis, after j scarlatina. It is altogether probable, however, that in : many cases the dropsy following scarlatina without al- : buminuria is secondary to concomitant anaemia. This is the view adopted by Henoch. Whatever be their ex- planation, such cases usually run no remarkable course. The general health is not much reduced. The urine is in normal amount, the various functions are fairly per- formed. With the disappearance of dropsy convales- cence is established. Scarlatinal nephritis is not associated with any especial phase or type of scarlatina. It is as frequent after mild as after severe attacks ; indeed, it is possible that the care exercised over those who have grave attacks of the fever, in proper nursing and surroundings, may furnish a safe- guard against renal complications. At all events, there is a widespread belief that the milder cases are more apt to be followed by nephritis and dropsy. Violent nephri- tis may certainly follow a scarlatina so mild as to have escaped observation. Individual predisposition and epi- demic type are probably the most important etiological factors, though at present enough is not known to jus- tify dogmatic statement. The nephritis and dropsy may occur without antecedent symptoms of scarlatina. In- stances of this are not uncommon. Several members of a family or of a school or asylum in which scarlatina has been known to prevail may exhibit dropsy and albu- minuria characteristic of scarlatina, without having mani- fested any other symptom of the disease. Such cases pursue an ordinary course generally, but at times develop a severity altogether unexpected. Inflammation op the Lymph Nodes and Connec- tive Tissue of the Neck. — Although Barthez and Ril- liet, and others, have observed cases of scarlatina in which there was no angina, in one form or another it is nearly always present. More or less hyperplasia of the neigh- boring lymph nodes also constitutes part of the ordinary phenomena of scarlatina. The infection is supposed to originate in the throat, the hyperplasia being due to re- flex irritation from the scarlet-fever contagium, or to the secondary streptococcus or staphylococcus or mixed in- fections. It has already been shown that the inflamma- tion sometimes leads to suppuration and even gangrene of the glandular and periglandular structures. This es- pecially occurs in scrofulous and rhachitic children, but is probably a result of septic absorption. The active symptoms become prolonged beyond those of simple scarlatina into the second, third, or fourth week, and even later, and merit some especial notice. They may not develop until as late as the third or fourth week, thus constituting true sequelce rather than complications. Usually the fever continues after the subsidence of the eruption, the pain and stiffness of the neck increase, and deglutition continues painful and difficult, or even al- most impossible. The mouth may be held open and saliva constantly dribble from it. The neck becomes hard, brawny, and swollen; the integument tense, smooth, and shining. The outline of the neck sometimes stands in line with that of the head and underjaw, and it becomes impossible to distinguish the enlarged nodes in the mass of inflammatory exudation. The patient is un- able to find repose, or to swallow food or fluids, unless in small quantities and with great pain. Rest is broken and unrefreshing. Suppuration reveals itself by dark-red, livid spots which soon fluctuate ; or it may be deep-seated and difficult to detect, or may point and discharge inter- nally. The parotid gland and periglandular tissue often become involved. At times more or less widespread necrosis may lay bare important muscles, vessels, and nerves, and involve large areas of tissue. These diph- theritic and gangrenous inflammations may give rise to phlebitis or arteritis with thrombosis, and embolism with metastatic inflammation. Compression of the larynx, of the trachea, or of the jugular veins may also result. At times pus may burrow into the deeper cervical struct- ures. Hemorrhage may also occur from exposed vessels. Baader 21 reported two cases of death from hemorrhage thus occurring. The extent of these phlegmonous in- flammations of the neck varies greatly. In most cases, after the evacuation of pus, recovery follows, though slowly. In more severe cases death may result from ex- haustion or from blood-poisoning. In healing, the scars may be insignificant, or, where granulation involves a large surface and is protracted, the resulting cicatrix may occasion deformity by its contraction. Retropharyngeal abscess, which has already been described, is not common. Schmitz, in the Child's Hospital in St. Petersburg, did not observe it once in 450 cases of scarlatina. Cases, how- ever, have been reported. Bokai reported it as occurring seven times in 664 cases; of these 2 were fatal. Lewan- dowsky 2a reported 3 cases, both resulting in recovery. Disorders of the Auditory Apparatus. — These are very important complications of scarlatina. Probably most cases of deafness acquired in early life are results of scarlatina. Of 85 cases of affection of the middle ear following this disorder, 18 had lost the sense of hearing in one or both ears, and 3 were deaf-mutes. 28 Milder de- grees of middle-ear inflammation arise by extension from the throat, and are simply catarrhal; but the severer forms are preceded by croupous-diphtheritic inflamma- tion of the fauces. The milder form of otitis media will cause the patient some earache, of which, if he is old enough, he will bitterly complain. Infants will indicate their sufferings by cries, by raising their hands to the ears, by rolling the head toward the affected side. If the Eustachian canal remain pervious, all inflammatory exu- dation may escape, and no symptoms, other than those 55 Scarlet Fever. Scarlet Fever. REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. mentioned, and slight and transitory deafness, may oc- cur. This latter symptom may result from the pressure of an enlarged parotid gland upon the external auditory canal. But in the severer forms the pain may be excru- ciating, the deafness more or less complete, and the fever high. The Eustachian canal becomes occluded from in- flammatory swelling, and exudation accumulates in the cavity of the tympanum. Headache may be violent. The drum membrane will be bulged outward from internal pressure, and will be reddened and swollen. The pent- up fluid, unless released by puncture of the drum mem- brane, finds an exit for itself by perforation. Extreme pain is often produced by pressure upon the tragus and over the mastoid process. Rarely, delirium may be fol- lowed by signs of meningitis from extension of the in- flammation from the middle ear to the dura mater, along the course of the middle meningeal artery. In mild cases the inflammation will subside, with or without perfora- tion of the drum, and hearing may be perfectly restored. In severer cases, timely tapping of this membrane may yet preserve the sense of hearing — but, unfortunately, it but too often happens that the ossicles of the ear and the ■tympanic membrane are destroyed ; the bony walls, even of the middle ear, become carious, and irreparable dam- age is done. The severer inflammations involve a croup - ous-diphtheritic process that often entails wholesale de- struction. According to Green, disease of the labyrinth, involving absolute deafness, may occur within a day or two. In such cases the watch held to the skull, the ear, or between the teeth, may not be heard. Green 54 thinks that when loud "clashing," "ringing of small bells," or " musical notes " are heard during scarlet fever or cerebro- spinal meningitis, these are apt to be immediate premo- nitions of labyrinthine disease; whereas the subjective sounds always accompanying acute purulent inflamma- tion of the tympanum are described as "hissing," "sing- ing, " "buzzing, " or " throbbing. " He also suspects that the fluid secreted in immense quantity — a clear, limpid serum — differing from the wine-yellow serum of tym- panic inflammation, may be labyrinthine peri- and endo- lymph. Pus may form in the mastoid cells. These 'changes may occur either as complications or as sequelae. Caries sometimes appears quite early, and the chronic otorrhcea thus set up may last for years, occasioning widespread disorder of both soft parts and bone. 25 In necrosis following middle-ear disease, the facial nerve may become involved with subsequent paralysis. Fatal hemorrhage from the ear may occur after scarlatina, from exposure of vessels from the diphtheritic processes. 26 Chronic posterior nasal catarrh, and necrosis of the bones of the nasal cavity, constituting various degrees of ozaena, sometimes follow the extension of the pharyn- geal inflammation to the nasopharynx. The eye may likewise be implicated in scarlet fever. Conjunctivitis may develop as a complication, or diphtheritic inflam- mation may extend along the lachrymal canal and in- volve the conjunctiva?. It may produce keratomalacia and even destruction of the eyeball. Retinitis after scar- latinal nephritis has been observed by Schlatter. Its course is favorable. Temporary blindness may be due to uraemia. Acute amaurosis after scarlatinal nephritis has been noted. 21 Transitory blindness, lasting for from twenty to sixty hours, has been observed by Ebert, 28 Henoch, 29 Tolmachew. 30 In a case of FOrster's it lasted eighteen days.. Inflammation of Joints. — Not very infrequently in- flammation of the synovial membrane of the joints ap- pears as a complication or as a sequel of scarlet fever. - The usual date of its occurrence is during the second week or later. It is often only indicated by pain with- out swelling, and may be limited to a single joint. In ; other cases a number of joints are involved, usually the ankles and wrists, knees and elbows. The hip-joints may be affected, and also the smaller joints of the extremities. The inflammation may betray all the features of acute rheumatism— the fugitive character of the inflammation, the metastases, the sweating, the fever, even the tendency to implicate the other serous surfaces, the pleurae, the 56 endo- and pericardium, and the meninges. Mahomed's 31 studies showed that, as the urine increases in quantity from the seventh to the fourteenth day, it loses its de- posit of lithates, and often its albumin (if this has been present). It is highly acid, and uric acid is abundantly thrown down by the nitric-acid floating test. It was at this period that he found the rheumatism most apt to occur. This rheumatism seems identical with ordinary acute rheumatism, but follows a less protracted course. Numerous writers have seen purulent arthritis as a sequel of scarlatina. It commonly occurs during the second or third week, and in most instances is monoarticular. Pyaemic arthritis usually results in suppuration, erosion, and destruction of the cartilage of the joint. According to Spender, 34 the wrist-joint is most often attacked, next in frequency the knee and hip. Recovery may take place, but usually death follows the discharge of pus and the formation of fistulous openings, from exhaustion, or from the further progress of the pyaemia. The approach of these complications, which are fortunately rare, may be recognized through the thermometer. Affections of the Heart and Pericardium. — Cheadle 32 quotes fifteen cases from West, in which endo- or peri- carditis, or both, supervened upon scarlatina. These did not occur during the acute stage, but during desquama- tion. He, however, considered them rather the result of urasmia and nephritis than of rheumatism. Henoch 33 re- lates two cases in which acute arthritis appeared during the first week of scarlatina, followed by severe chorea and loud mitral murmur. As to the cardiac symptoms, Cheadle concludes that they occur in scarlatina as results both of scarlatina and of nephritis. He also thought that " scarlatina would appear to have a special influence in causing dilatation and hypertrophy without accom- panying valvular disease." Endocarditis, which not un- commonly arises, may be very insidious, and may even pass undetected if not looked for. Probably not a few old valvular affections have originated in attacks of scarlet fever. Acute pleuritis or pericarditis may accom- pany joint inflammation, or may occur independently. In severe cases they may result in purulent exudation and ultimately terminate fatally. Sometimes the serous inflammations are pyaemic. Endocarditis ulcerosa may begin in this manner. In the most severe and malignant cases of scarlatina the heart muscle undergoes, first, cloudy swelling, and later, fatty degeneration, especially on the right side. This is the occasion of death from heart failure in many malignant cases. Affections of the Respiratoi-y and Alimentary Tracts.— Inflammation of the respiratory tract is decidedly un- common in milder scarlatina. Bronchial catarrh is apt to complicate serious cases. Pneumonia is seen some- times as a secondary complication following nephritis, diphtheria, etc. Disorders of the intestines are also un- common. Diarrhoea, when present, is usually associated with severer forms. Diphtheritic enteritis was the most frequent sequel in the cases observed by Fleischmann. Peritonitis may occur as a rare complication. Henoch has seen bedsores complicate scarlatina. Sequel^.— The affections that constitute true sequela? usually are disorders that persist after scarlet fever has completed its course, having begun as complications. Thus are encountered chronic buccal, pharyngeal, nasal, and aural inflammations, nephritis (which, as a rule ul- timately entirely disappears), or inflammation of 'the various serous membranes. In some cases, marked by severe eclamptic seizures, there results contraction of different groups of muscles, giving rise to permanent deformity. Chorea may develop in connection with the arthritis and endocarditis. Progressive involvement of the limbs with paralysis and wasting may rarely be met with, showing the clinical features of an ascending spinal paralysis. Cerebral thrombosis and hemiplegia rarely occur. Mania has been known to follow scarlatina 3B Gangrene, apart from that resulting from diphtheria of the throat, is infrequent. Noma has been observed by a number of writers (Barthez and Rilliet, Heyfelder Bon- REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Scarlet Fever. Scarlet Fever, ing, and others), but it is notably less common than after measles. Necrosis of the nasal cartilage was observed by Henoch during convalescence. Concurrence with Other Specific Affections. — Scarlet fever may be complicated by, or may complicate, other acute exanthemata, not to the extent, however, that many writers believe. Mayr and Hebra, indeed, taught that scarlatina never coexists with measles or smallpox. This question is involved in much obscurity. Scarlatina may be simulated by a variety of affections that may in fact coexist with the exanthemata, by vari- ous erythematous eruptions, by the roseola that often precedes and accompanies the eruption of smallpox, by certain anomalous forms of measles, and by various medicinal rashes — those caused by belladonna, copaiba, chloral, and especially cinchona and its preparations; These considerations and faulty methods of observation and recording lead to the rejection of much of the evi- dence adduced in favor of these coexistences. After all faulty observations are thrown out, however, there still remains strong proof that scarlet fever may coexist with other exanthems. It will be everywhere admitted that one exanthem may follow close upon the heed of another. Prior 36 noted a case in which scarlatina developed on November 18th, varicella on December 2d, and measles on December 13th. When the two exanthems develop , simultaneously, there will often remain much doubt, in the absence of evidence of the double exposure of the unprotected individual and of his subsequent double pro- tection. Where one precedes the other by a few days, the difficulties are not so great. Scarlet fever has been observed as complicating, or complicated by, other exan- themata by Steiner, 3 ' Monti, 38 Thomas, 39 Fleischmann, 40 Fabore, 41 Stillen, 42 Zechmeister, 43 Backer, 44 Dornig, 46 Lewis Smith, 46 Murchison, 41 and many others. The com- binations and the order of occurrence have been noted as follows, viz. : Scarlatina and measles. Measles and scarlatina. Scarlatina and smallpox. Smallpox and scarlatina. Scarlatina and vaccinia. Scarlatina and varicella. Varicella and scarlatina. Scarlatina and typhoid fever. Concurrence of scarlatina and ROtheln has not been re- ported. A probable source of fallacy is the scarlatini- form rash that is often observed in smallpox, and occa- sionally in typhoid fever; indeed, Simon asserts that Fleischmann has even made this very error. The possi- bility of these rashes should always be held in mind when questions of concurrence are under consideration. When scarlet fever develops after smallpox the eruption in- volves the parts of the skin left free by the lesions of smallpox, more especially about the chest and abdomen. When the two exanthems appear simultaneously, their course is shortened ; " the second mitigates the first and becomes shortened itself," excepting, according to Fleischmann, when severe smallpox occurs in connection with scarlatina, when death usually results. The same author asserts that if scarlatina appear at the period of maturation of smallpox, the latter, in mild cases, is shortened and mitigated. When scarlatina complicates measles, the latter is shortened, but the scarlatina thus occurring may be mild or severe. Barthez and Rilliet noted that in scarlatina-measles, when the former malady predominates, bronchitis is more marked; but when measles is most severe, faucial angina is worse. All of these statements lack such evidence as would entitle them to unqualified acceptation. Very often neither disease is well developed, and the true condition may be very difficult of recognition. In America these concurrences are more uncommon than they seem to be abroad. Whooping-cough has been known to complicate scar- ■ latina, and a number of non-specific affections may occur ', simultaneously with it. These coincidences are purely accidental and present no peculiar interest. Biart 48 has ' reported psoriasis as following scarlatina. Barthez and Rilliet assert that tuberculous children verj' rarely have scarlatina. Some chronic affections partially or entirely disappear during an attack of scarlatina. Among these may be especially mentioned certain cutaneous affections, eczema, psoriasis, etc., but they usually reappear upon the establishment of convalescence. Surgical Scarlatina.— Sir James Paget, in 1864, and again in 1875, 49 declared that patients who have under- gone surgical operations are peculiarly susceptible to the action of the scarlet-fever poison. This question has at- tracted a great deal of attention. In France, Trelat was the first to accept this view, though scarlatinoid rashes had been observed by Civiale, Germain See, Tremblay, and others. Similar rashes were reported by Hutchin- son, Hilton, Bryant, Lee, Moore, Stirling, and others. They had generally been considered as of septicamiic ori- gin. In 1879 Paley and Goodhart 60 and House 61 reported observations of endemics of scarlatina in the Evelina Hospital for Sick Children and in Guy's Hospital. The first-named authors based their report upon twenty-five cases of scarlatina occurring in surgical patients. Of these nineteen were known to have been exposed to scarlatina, and all the rest, save one, were known to have had possible sources of infection. House's paper was based upon four cases of surgical scarlatina. The epi- demic tendencies ceased upon the establishment of isola- tion, and one cannot doubt their scarlatinal origin . These writers were careful not to assert that all such red rashes should be attributed to scarlatina, or that there is not " such a thing as a rose rash in a typical case of septicae- mia " ; but they believe that when occurring in groups they may nearly always rightly be attributed to scarla- tina. Riedinger and Howard Marsh also agreed that there exists in wounded persons a predisposition to scar- latina. While Holmes coincided with these views, he, however, declared that many cases of " surgical scarlet fever " are really due to pyaemia and other causes. Most recent writers incline to the opinion that these eruptions are due to true scarlatina. When any epidemic tendency is shown, every one will agree with such conclusions. This cannot be granted of rashes occurring in isolated cases. Of 25 cases reported in Paley and Goodhart's pa- per, scarlet fever attacked 17 after operations; 7 were without any wound whatever, and 1 had only an old sinus. In many of the cases reported by other writers there was no open wound. These reporters, unfortu- nately, most rarely note whether their patients had ever previously had scarlatina. Most children, when first ex- posed to the contagion of this disease, become infected. Is it remarkable that they are unable to withstand it when it attacks them, weakened by injury or surgical operation? Apart from epidemic influence, it is proba- ble that scarlatiniform eruptions in the wounded may justly, in a large proportion of cases, occur quite inde- pendently of scarlatina. Rashes of septicemic origin are well known to occur. Various fugitive eruptions often result from emotional and nervous irritations, or from the ingestion of certain articles of food or medi- cines. It must be admitted that scarlatiniform septi- cemic rashes are uncommon. But there is excellent evi- dence that they occur. 52 Attempts have been made to establish a differential diagnosis for the surgical scarla- tiniform rash. Cheadle, 63 for example, claimed that it has specific characters in not often being universal, and in being confined to the body and parts covered by the clothing ; that it rarely lasts twenty -four hours, and that it never desquamates. He also asserted that there is no tonsillar swelling, nor glandular enlargement, nor the peculiar " strawberry tongue. " Such points of differenti- ation do not appear to be well founded. Scarlatiniform eruptions also occasionally follow the ingestion of certain drugs. They may be evoked by belladonna, copaiba, opium, chloral, mercury, and other drugs, but, above all, by cinchona bark and its derivatives. These eruptions are much more common than is generally supposed. Quinine has been frequently given to those who have been injured or submitted to surgical operations, and be- yond question eruptions evoked by it are often attributed 57 Scarlet Fever. Scarlet Fever. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. to other causes. A number of eruptive forms are ob- served, but the one of especial moment is the scarlatini- f orm rash. At the onset ifr often cannot be distinguished from scarlatina. Beginning with high fever, and often with sore throat, the eruption appears upon the face, chest, and neck, and within twenty-four hours the entire surface may present a bright scarlet aspect. At the end of this period the resemblance may be made perfect by the " strawberry tongue. " Up to this point the diagnosis may be impossible. Barely, it remains so throughout the attack, especially when the ingestion of the cinchona preparation is continued. Usually, however, after thirty- six or forty -eight hours the type of normal scarlatina is departed from. The fever rapidly decreases, tlxe angina disappears, and the rash either fades or acquires features unlike those of true scarlatina. It becomes duller, more papular, and often tends to form miliary vesicles. Eventually it may resemble ordinary "prickly heat." Sometimes, however, the scarlatinal features are pre- served throughout. In either case a copious desquama- tion is sure to follow. This is usually lamellar. Even albuminuria has been known to add to the embarrass- ment of the diagnostician. These medicinal and septi- csemic rashes occur in isolated instances, and may at times baffle the keenest diagnostic powers. We may conclude that unprotected, persons who have suffered injury or who have undergone surgical operations are rather more liable to scarlatina, than the unprotected healthy. Scarlet fever is more apt, than the other exan- themata to attack such persons, because its symptoms vary within such wide limits that it often escapes the at- tention of those who readily detect other infectious dis- orders and provide against them. "When an epidemic tendency of the symptoms we have been considering is shown to prevail, it may be confidently concluded that true scarlatina is present. Septicaemia is occasionally ac- companied b3 r a scarlatiniform rash which does not de- pend upon the scarlatinal poison. These rashes are often attributed to scarlatina. Scarlatina Puehperalis. — While pregnant women seem to enjoy a remarkable immunity from the specific eruptive fevers, it is well known that during the puer- perium they are especially subject to them after expos T ure, and that the disease is then apt to pursue a grave and often fatal course. Not only scarlatina, but measles and smallpox may affect the lying-in woman with such malignity that the symptoms may not acquire the feat- ures of the maladies to which they belong, but become indistinguishable from those of malignant septicaemia. Scarlatina is especially liable to attack the lying-in woman. It may assume the virulence referred to, or it may pursue a course in which it is difficult to determine whether its symptoms are septic or really scarlatinal, or, finally, it may appear with typical and unmistakable features. Not a few writers have thought that the scar- latinal virus may produce in the puerperal woman septi- caemia, pure and simple. This view is maintained by Playfair, Braxton Hicks, Leishman, and others. They assert that in these women, after exposure to the specific contagium, symptoms of acute blood-poisoning may be developed, and not those of scarlatina. On the other hand, just as in septic conditions, independent of puer- peral causes, an erythematous rash and other scarlatinal symptoms may be observed in which true scarlatina has no part, so must one guard against assigning to scar- latina every scarlatiniform rash occurring in obstetrical cases. It may be septic in origin, or it may be a medi- cinal eruption. When a septic, or medicinal, or other form of erythema can be excluded, and when exposure to scarlatinal influence is followed by any degree of the symptoms we are considering, are we in atypical cases to look upon the results of the infection as distinctly scarla- tinal? More recent writers regard the scarlatinal nature of the disorder as preserved, and as capable of further dissemination. It has not been determined to what ex- tent women who have already had scarlatina preserve an immunity from further attacks during their lying-in period. It would appear that the intensified predispo- sition of the childbed carries with it an increased liability to second or third attacks. Busey 64 has related a case, in which the patient had already had scarlet fever. Other such cases are upon record. 66 In all probability the scarlet-fever contagium evokes scarlet fever, and not septic disorder, in the puerperal woman, whose systemic condition affords peculiar sus- ceptibility to its influence, and predisposes her to a viru- lence of its activity that often leads to disastrous results. The less remote the date of delivery the graver the course of the malady is apt to be. If the symptoms do not appear before the seventh day, their development is no longer to be feared. Olshausen 66 collected from the lit- erature 141 cases, of which the scarlatina attacked, dur- ing pregnancy, 7; in S it immediately followed delivery; in 62 it occurred on the first and second days; in 27 on the third day ; in 22 after the third day. After the fifth day none was attacked. While the puerperal woman shows intense susceptibility to scarlatina, the pregnant woman enjoys a marked immunity from it. Olshausen thinks, however, that the period of incubation may last for months during pregnancy, but only a few days dur- ing childbed. This opinion he rests upon no solid basis. Primiparae are more often attacked than multipara. The mortality in puerperal scarlatina is high. In the series just alluded to it was 48 per cent. (3 cases during pregnancy and 64 in childbed). In the recorded cases studied by McClintock " the mor- tality was over 66 per cent. In 34 cases at the Lying- in Hospital the death rate was 30 per cent. Of 10 deaths at this hospital, 8 occurred when scarlatina had developed within thirty-six hours after delivery. Of 18 patients attacked on the first or second day, 8 died. Of those attacked on or after the third day (16 in num- ber), all but 2 recovered. McClintock also quotes Dr. Halahan's cases, as follows, viz. : 3 patients, ill of scar- latina at the moment of delivery, died; of 5 attacked during the first twenty -four hours, but 1 recovered ; of 10 attacked during the second day, but 1 recovered; of 4 attacked during the third day, but 1 recovered. The remaining 3, attacked on or after the fifth day, recov- ered. Braxton Hicks' 68 contributions to this subject have been most important. He believes that in one-half of the cases the usual symptoms of scarlatina are mani- fested, and that the disease almost always commences after the third day after delivery. The death rate will be greater the earlier after labor the symptoms develop. Though lying-in women are peculiarly liable to scarla- tina, they are frequently exposed to its influence without detriment. Women have not seldom been confined in the room, even in the bed, occupied at the same time by scarlet-fever patients, without experiencing the slightest interruption of their normal convalescence*, a result that is not astonishing in protected persons if the scarlatinal virus transmits only scarlatina, but which would not be expected were the virus equally competent to communi- cate septicaemia in these cases. While a large proportion of cases pursue a grave and anomalous course, there are many others in which a perfectly typical scarlatina is observed, without seriously endangering life. Secondary inflammations are not unknown. Metritis, cellulitis, peritonitis, or pyaemia may be developed, but whether these are direct results of scarlatina or of the puerperal condition is undetermined. The exact nature of puerperal scarlet fever and surgi- cal scarlet fever will remain in doubt until a specific or- ganism of scarlet fever can be isolated. At present this is impossible. In the mean time it is interesting to note that with the development of aseptic and antiseptic methods in surgery and obstetrics, less and less is heard and seen of " puerperal " and " surgical " scarlet fever. Relapses and Recurrences.— There are recorded numerous instances of relapse of scarlet fever within a short period after the original attack, and second or even third attacks after a more or less prolonged interval are well known to occur. By a relapse is meant a second attack of scarlatina that is evidently due to the persistent activity of the influences that excited the first attack. 58 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Scarlet Fever. Scarlet Fever. Within a short period (three days after deflorescence in a case of Woldberg's 59 ) after the original attack all the symptoms are repeated ; the initial disturbances, the fe- ver, the eruption, the angina, and other phenomena, with ensuing desquamation, are developed. It is held that the second attack is but the completion of the first, that it occurs after an incomplete primary attack, and that it tends to be severe in proportion to the mildness of the first, and often to affect in eruption only those parts which were originally spared, 60 imparting thus to the second eruption the appearance of scarlatina variegata. The relapse may be accompanied by complications of throat, kidney, and other disorders, that were not present in the earlier disorder, and vice versa. These relapses are usually very rare, but seem to be more frequent in certain epidemics. Thomas applies the term pseudo relapse, or reversio eruptionis, to those cases in which the exanthem returns before the disorder has entirely completed its course. Trujawsky found the interval between the two attacks to be from seven to ten days, with an average of eight and five-eighths days. The intermissions are completely afebrile. These relapses have been explained by, (1) a recrudescence of the original contagion, and (2) the ac- tion of a newly acquired contagion from a source differ- ent from the original one. The prognosis is often graver than in the primary attacks. Recurrences or attacks of scarlet fever occurring after a more or less protracted interval are more common, and are due to fresh infection. They may occur at al- most any period. Trujawsky 61 noted, in 300 cases of scarlatina, 18 patients who had had a former attack. Of these 4 were under ten years of age, 10 were over ten years, and 3 were adults. The interval between the at- tacks varied from one and a half to seven years. Thomas had personal knowledge of a case in which a second at- tack occurred. Willan never saw one. Many years may elapse between the two attacks, as when a mother who had the disease during childhood again develops it by contagion from her child. Heyfelder himself had a sec- ond attack twenty -seven years after the first one. Tru- jawsky thought that immunity is greater against conta- gion originating at the home or in the neighborhood of the patient than when it is brought from a distance. A third attack in the same individual may be observed (as in Richardson's case), and there are reports of repeated attacks of scarlet fever. Bernouilli, 68 for example, men- tions the case of a woman, fifty years of age, who expe- rienced in rapid succession six attacks of an exanthem indistinguishable from scarlatina. Other similar cases are on record, but their consideration suggests that they may rather have been forms of medicinal eruption. Acute exfoliative dermatitis may also be mistaken for scarlet fever, and may attack repeatedly the same person. Rashes resembling scarlatina may occur in various other affections, such as typhoid fever, smallpox, etc. Hallo- peau and Tuffier 63 saw a scarlatinif orm eruption in acute rheumatism, in which there were two relapses with in- tense erythema, followed by copious desquamation. The possibilityof all such cases being mistaken for scarlatina should be remembered. It is a rather singular fact that many persons suffer from angina whenever they are brought into close personal relationship with those who have scarlet fever. This is commonly mild, but may oc- casion serious discomfort. Those who suffer thus from exposure to the scarlatinal influence do not communicate scarlatina to unprotected persons. Mild desquamation is said to have been noted in some such cases. This, how- ever, would indicate a true scarlatinal infection. Pathological Anatomy. — In most fatal cases every trace of eruption disappears after death. After a very intense exanthem, more or less redness may remain. Af- ter malignant cases blood extravasations may present the only post-mortem discoloration. The organs primarily affected are the skin and the throat; the principal com- plications arise in connection with the ear and cervical lymph nodes; and the chief sequela is nephritis. The heart may be affected as a result of the general septic condition, but its lesions are more frequently dependent upon the changes wrought in the kidneys. Skin. — Remy M and Neumann 66 have investigated the histology of the skin in scarlatina. Remy found the capillaries of the papillary layer dilated and hyperamic, and filled with leucocytes which were enlarged and of different sizes, but not so large as in leukaemia. The vascular wall was not altered. The epidermis was thick- ened by increase of its cylinder-cell layer. The horny layer, sebaceous glands, and hairs were unchanged. The sweat glands were empty and shrunken. Neumann found the cells of the rete swollen. In many specimens the prickle cells were elongated, and here and there formed interspaces in which exudation cells were em- bedded, and into which small blood extravasations often occurred. Exudation cells extended abundantly as far as the horny layer, and at the orifices of the follicles they were very numerous. In measles this epidermal layer presents no marked changes ; hence it is not difficult to understand why the epidermal cells are so much more lia- ble to carry the contagium in scarlet fever than in mea- sles. The corium was swollen, the fibres were thickened, partly separated by proliferation, partly by enormously dilated vessels that were at times bulbous. It is this ex- udation into the epidermal layers that causes the loosen- ing of the horny layer from its bed, and the characteristic desquamation. LOsehner and Fenwick have also noted this infiltration of the rete. The latter writer found the basement membrane of the sweat glands also thickened and the lining membrane gone in places, but in other places it was increased so as'to occlude the sweat glands. The deeper layers were normal throughout. The scarlet- fever exanthem, then, consists of hyperemia with exu- dation. Remy found the changes he describes regularly and uniformly distributed. Throat. — The throat symptoms, as constant as are those of the skin, are due to lesions that are always rec- ognizable after death. The milder alterations offer noth- ing characteristic; they are identical with those of phar- yngeal catarrhal inflammation. In more intense degree follicular inflammation, with suppuration and ulceration, is superadded, and oedema becomes more prominent. The inflammatory changes extend beyond the pharynx into the buccal and nasal cavities, while parenchymatous tonsillitis and inflammation of the cellular tissues of the throat and neck develop, with, sometimes, extensive gan- grene. According to Harlin (Thomas), scarlatinous angina is specific, and is marked by "a deep, bluish-red injection of the mucous membrane of the tonsils and neighborhood, of the uvula, of the posterior portion of the tongue in the neighborhood of the highly swollen papillae, of the posterior portion of the region of the cricoid cartilage, and of that portion of the pharynx which includes these different parts, and measures about two inches in breadth. " This coloring is said to be sharply outlined in the direc- tion of its transverse diameter. Among the earlier writers on scarlet fever, and as late as the years 1883 and 1884 when the Klebs-Loeffler bacil- lus was discovered and demonstrated as the specific cause of diphtheria, much space was devoted to the nature of the diphtheritic membrane so often formed in scarlatin- ous angina. The weight of opinion was that the scar- latinal virus, acting upon the virus of the throat, caused a coagulation necrosis that resulted in the production of the membrane, although it was held that occasionally the scarlatinal process might be complicated by a true diph- theria. The result of modern bacteriological researches has shown that the diphtheritic membrane is in all prob- ability the result of the activity of streptococci and staphylococci or of a mixed infection. There may be, of course, a Klebs-Loeffler infection as well. The influence exerted by the scarlatinal virus in the production of the pharyngeal inflammation cannot be determined in the present state of our knowledge of the specific cause of the disease. Kidneys. — Bacteriological examinations of the tissues in scarlet fever frequently show general streptococcus 59 Scarlet Fever. Scarlet Fever. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. infections, probably having their origin in the lesions in the throat. In a number of these cases there may be found in the kidneys extensive lesions which bear no relation to the presence or absence of streptococci; on the other hand, streptococci may be found in the kidney without any lesion of the kidney." We may assume, therefore, that at times the pathological changes are a result of sol- uble chemical poisons produced by the virus of scarlet fever or by the activity of the associated secondary in- fections by streptococci and staphylococci, and at times the lesions are due to direct infection of the kidney by organisms conveyed to it by means of the blood. Councilman, who has made recent and extensive studies in the pathology of scarlet fever, divides the kidney lesipns into two classes : (1) Representing simple degen- eration of the epithelium; and (2) representing marked changes in the tissues of the kidney. The lesions of the second class he divides according to their anatomical dis- tribution into (a) interstitial, in which there is marked proliferation of the interstitial tissue of the kidney ; and (b) capsular glomerular, in which the lesions are chiefly confined to the glomerulus and its capsule." The first, the purely degenerative form, appears at the beginning of the exanthem, or a few days later, and dis- appears in a few days or weeks. It rarely excites oedema, and hardly ever kills. It is analogous to the alterations productive of the febrile albuminuria of many infectious diseases. Cloudy swelling and proliferation of the tubu- lar epithelium, and, later, fatty degeneration, are shown. Within the tubular lumen are hyaline and granular cyl- inders, round cells, and desquamated epithelium. The second type, the interstitial, was first described by Wagner as the lymphoid kidney." The kidney is swollen, the capsule is easily stripped from the cortex, and the surface is moist, whitish, and opaque. Usually there is no hemorrhage, although in some cases puncti- form areas may be found in the cortex and intermediate zone. The epithelium may show the changes character- istic of the first or purely degenerative class. The most marked feature of this class of cases is the thickening of the interstitial tissue and the abundant infiltration with round cells, most of which are plasma cells, with some lymphoid cells and polynuclear leucocytes. This form of nephritis may be markedly developed and yet not give rise to clinical symptoms any more pronounced than are seen in the first or purely degenerative class. It is not confined to scarlet fever, but may occur in the course of diphtheria, measles, and other infectious diseases of chil- dren, but is not commonly produced in adults in the same class of diseases. The third form of nephritis, the capsular glomerular, is a more frequent accompaniment of scarlet fever than of any other infectious disease, but is not so common as the acute interstitial form. The kidney is swollen and hypersemic, the markings of the cortex are obscured or effaced, while the hemorrhagic areas give to the kidneys a mottled appearance. Histologically the chief lesion of this form consists of a proliferation of the capsular epi- thelium combined with hyperplasia of the connective tissue. The proliferation of the capsular epithelium in- creases the pressure upon the glomerulus so much as to interfere with the blood supply and hence with the se- cretion of urine. It is this form of nephritis which is especially liable to give rise to dropsy, to greatly dimin- ished amounts of urine, or to ursemia. The clinical ap- pearance of the urine is that of an acute diffuse nephritis, the amount of blood, albumin, and casts depending largely upon the severity of the infection. Recovery may take place even from the severe forms of capsular glomerular nephritis, but chronic nephritis is a sequela in a certain number of cases. Friedlander holds this to be the only characteristic scarlatinal nephritis. These three forms of nephritis— the simple degenera- tive, the interstitial, and the capsular glomerular— may usually be recognized histologically, but transition changes occur. It is not always practicable to make sharp definitions between early and late changes. The first set of changes are chiefly limited to the cortex. 60 They are : 1. Increase of nuclei (probably epithelial) cov- ering the glomeruli. 2. Hyaline degeneration of the elastic intima of minute arteries, especially of the afferent arterioles of the Malpighian tufts. The intima of these vessels is swollen here and there into spindle-shaped hyaline masses, causing narrowness of the lumen. There is similar hyaline degeneration of the capillaries of the glomeruli, rendering them often impermeable. These degenerated parts become fibrous in appearance, and Bowman's capsule becomes thickened. 3. A third change is multiplication of the nuclei of the muscularis of the minute arteries, with increased thickness of their walls. This is greatest at the point of entrance into the glomer- uli, but is also distinct in other arteries of the cortex and in the base of the pyramids. There are also swelling of the epithelia of the convoluted tubules and proliferation of their nuclei, especially of the tubules close to the afferent arterioles of the glomeruli. In some cases the epithelium of the large tubules of the pyramids is de- tached. Klein's 66 observations, (1) that the hyaline changes readily affect the arteries near their point of branching, and (2) that the hyaline substance is of the nature of elastic tissue, agree with the conclusions of Neilson concerning the arteries in various cerebral disor- ders and in many infectious diseases. He does not think that the anuria and uramic poisoning in scarlatina, when the kidney does not show conspicuous change, are due to compression of the vessels of the glomerulus by the nuclear germination, as claimed by Klebs, 6 ' but rather to the changed state of the arterioles, and suggests that the increased formation of arterial muscular fibres, under the stimulus supplied by the disease, may cause a con- tractility that obliterates the calibre of the arterioles and shuts out the glomerulus from the circulation, and thus, so far as it operates, suppresses the secretion of urine. The parenchymatous changes found in the early stages are slight and difficult to detect, the cloudy swelling and granular degeneration being limited to small portions of convoluted tubules. The second order of changes be- gins about the ninth or tenth day. They are interstitial , as well as parenchymatous. Round cells are found around the larger vascular trunks, spreading into the bases of the pyramids and into the cortex. This process begins about the end of the first week, and gradually in- creases until portions of the cortex, rarely portions of the bases of the pyramids, are converted into pale, firm, round-cell tissue, in which the tubules become compressed and obliterated. The parenchymatous element of the nephritis consists in crowding of urinary tubules with lymphoid cells and various kinds of tube casts, and fatty degeneration of the epithelium of the tubules. This grows more marked with the advance of interstitial changes. The round-cell infiltration of the cortex begins at the roots of the interlobular vessels, spreading rapidly toward the capsule of the kidney, and laterally among the convoluted tubes around the glomeruli, at first between the medullary rays, but later encroaching upon them. Portions of the cortex may be converted into firm, pale, bloodless cellular masses in which Malpighian tufts and urinary tubules become more or less destroyed. In one case renal embolism was encountered; both interstitial and parenchymatous inflammation was very intense. The kidney was markedly enlarged. Klein also noted deposition of lime in the epithelium and lumina of the tubules, first of the cortex and then of the pyramids, at an early stage of scarlatina, when only slight changes are otherwise shown. He concludes that cases of scarlatina which are fatal after the ninth or tenth day usually show more or less well-marked interstitial nephritis. Lymph Bodes.— Peculiar changes have been noted in the lymph nodes by Klein. In addition to the ordinary inflammatory infiltrations which he describes as occurring in the lymphatic follicles connected with the organs of the throat and in the lymph nodes of the neck, the ordi- nary lymphoid cells are greatly diminished in number, and are replaced by large granular cells containing num- bers of germinating nuclei. Liver.— This viscus becomes slightly enlarged from REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Scarlet Fever. Scarlet Fever. cloudy swelling. In one case Klein noticed, after two days' illness, acute interstitial hepatitis. The middle and internal coats of some arteries show the same altera- tions as in the kidneys. Wagner observed lymphoid new formations and numerous collections of cells and nuclei, especially in the interacinous connective tissue. Spleen.— In the spleen the changes are uniform and constant. They are : 1. Enlargement of the Malpighian corpuscles. 2. Hyaline degeneration of the intima of the arteries. 3. Proliferation of the nuclei of the muscular coat of the ultimate arterioles, with increased thickness of their walls. 4. Hyaline swelling and degeneration of the adenoid tissue around the degenerated arteries. 5. In the central parts of the Malpighian corpuscles the or- dinary nuclei of the lymph cells disappear, and in their stead are found large hydropic cells containing pigment (Klein). Other writers assert that there is no uniformity in the splenic changes, beyond a slight enlargement. Biermer has observed enormous enlargement of the Mal- pighian bodies. Intestines. — Disorders of the alimentary canal are not frequent in scarlatina, and when they occur it is usually in grave cases. They then not infrequently constitute the principal complicating lesion. In the cases of Fleisch- mann, diphtheritic enteritis was the most common sequel. The peculiar " shaved-beard appearance" of Peyer's patches has been at times observed, and at times these patches and the solitary glands are prominent, reddened, and inflamed, with associated tumefaction of the mesen- teric glands (Harley). Barthez and Rilliet show, how- ever, that in cases in which the typhoid-like lesions have been discovered, the symptoms shown during life did not resemble those of typhoid fever; and conversely, cases of typhoid scarlatina cannot be expected to reveal these lesions after death. Enteritis is more often catarrhal in nature. It has been asserted that in scarlatina the exan- them invades the mucous membrane to the same degree as the skin. Post-mortem evidence of this, however, is by no means constant. The glands throughout the ali- mentary tract are sometimes swollen, and sometimes form small ulcers and extravasations. Brain. — It is rare that even the most intense cerebral symptoms occurring in the course of scarlet fever are due to meningitis. Hyperaemia of the brain and meninges, with great venous engorgement, is often seen, but signs of pronounced change are extremely uncommon. Ear. — An acute otitis media is the most common affec- tion of the ear met with in scarlet fever. The inflamma- tion is especially likely to result in the destruction of tis- sue, the formation of adhesions, and the establishment of a long-continued suppurative process with accompany- ing necrosis. Periostitis and osteitis occur in connection with affec- tions of the joints, of the nose, of the pharyngeal and aural cavities, and of other parts, but afford nothing characteristic. Neither do the general serous surfaces show peculiar lesions. The condition of the blood and blood-vessels after certain rapidly fatal cases is impor- tant. Sometimes the blood is very fluid and black. At other times clots are abundant and firm ; again, it may have become diffused throughout the tissues. Remy has seen all the vessels of the papillary layer of the skin filled with coagulated blood. Thrombosis of the sinuses has been noted after scarlatinal diphtheria (Thomas). Heart. — Fatty degeneration of the heart following cloudy swelling, with dilatation, occurring particularly in the walls of the right ventricle, is a frequent result of scarlatina, as it is of other infectious disorders. Diagnosis. — Scarlet fever must be distinguished from measles, rubella (Rotheln), roseola variolosa, scarlatini- form rashes of septic or medicinal origin, certain idio- pathic erythemata, and diphtheria. From measles it differs in its shorter incubative stage, and in the charac- ter of its prodromes. In the former affection there are symptoms of coryza and bronchitis, with photophobia, sneezing, coughing, and the appearance of Koplik spots on the mucous membranes of the cheeks and lips (see Measles), while in scarlatina the prodromal symptoms es- pecially involve the throat and in children are frequently associated with vomiting. In scarlatina the eruption begins to appear during the first or second day ; in mea- sles during the third or fourth day. During the course of scarlatina there is an absence of catarrhal symptoms for the most part. There are the characteristic sore throat and enlarged papillse on the sides and tip of the tongue, the peculiar "strawberry tongue" (after the first two or three days), the well-defined eruption, the more protracted fever, the pronounced desquamation, and the tendency toward renal complications. The eruptions differ both in their development and in their distribution in the two affections. In scarlatina the face is characteristically invaded by the eruption, which entirely spares the area about the mouth, and is nowhere copiously developed in this region ; while in measles the eruption is, probably, most intense upon the face. The macules in measles are large, irregular, and mostly papular. In scarlatina the eruption is punctate and more regularly distributed, not elevated ; it is scarlet in color, and generally coalescent, while in measles it is more discrete, elevated, arranged very extensively in forms of crescents and segments of circles, with greater or smaller areas of healthy skin be- tween the lesions, and is of a darker raspberry color. In measles the stage of eruption lasts for from three to four days, and begins to decline as soon as the eruption upon the lower extremities becomes complete. It occupies about thirty -six hours in attaining its acme. In scarla- tina this stage lasts for from two to six days or more. It attains its acme in about eighteen hours. In measles there is a rapid return to a normal temperature in uncompli- cated cases, while in scarlatina both eruption and fever decline more slowly. The conjunctival, nasal, and bron- chial catarrh of measles is absent in scarlatina. In mea- sles the tongue remains coated throughout. Sore throat is constant in scarlatina, quite uncommon in measles, and when present is almost invariably only catarrhal. The fever in scarlatina is at once more intense and more pro- tracted. The desquamation of scarlatina is pronounced and lamellar; that of measles insignificant and branny. The presence of leucocytosis, not otherwise to be ac- counted for, is evidence in favor of scarlet fever and against measles. Scarlatina is frequently complicated by diphtheritic pharyngitis and renal inflammation, measles by inflammations of the respiratory apparatus. The eruption of rubella (Rotheln) more closely resem- bles that of scarlatina. It is paler, more discrete, and its lesions are larger and more distinctly papular. It is more transitory, and fades almost without desquamation, which, when present, is branny. R5theln, moreover, has a longer incubation, almost no prodromal stage, sometimes marked catarrh, and but slight elevation of temperature. It is feebly contagious, of much shorter duration, and is hardly ever followed by nephritis and dropsy. The diagnosis is difficult only when the erup- tion of rubella becomes confluent. Here, however, the confluence involves certain areas. It is sharply circum- scribed by normal integument, and shows in contrast the outlying characteristic lesions. It is of a pale rose-red, and not of a scarlet color, and is accompanied b}' the pe- culiar symptoms of rubella, and rarely lasts more than thirty -six hours. Both measles and rubella may at times closely resemble the milder forms of scarlatina, and from the eruption alone the diagnosis maybe difficult; but a consideration of all the symptoms will usually lead to correct conclusions. The presence of leucocytosis, in the absence of other conditions to account for it, is strong evidence in favor of scarlet fever. Roseola variolosa should excite embarrassment only when it occurs before the peculiar eruption of smallpox has appeared. It is less general, is more like a simple diffuse erythema than is scarlatina, and is so speedily fol- lowed by the characteristic vesicular eruption that doubt will soon be dissipated. Its coexistence with the essen- tial eruption may excite suspicions of a concurrence of scarlatina and smallpox. Such an error may readily oc- cur. Obstetrical and surgical scarlatina have already re- 61 Scarlet Fever. Scarlet Fever. REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. ceived attention. When erythema begins near a wound and becomes scarlatiniform in spreading, a septic origin must usually be allowed, though instances of scarlatina thus beginning have been reported; otherwise, septic erythema is more circumscribed and irregular. Scarla- tina in the wounded and in lying-in women may be per- fectly typical. Medicinal eruptions have unquestionably been at the bottom of many errors of diagnosis. It has been shown that many drugs may excite eruptions and general symp- toms very like those of scarlatina; but for the most part they are simple active hypersemias, such as are produced by the action of belladonna upon the cutaneous arterioles. Such eruptions differ from that of scarlatina in the ab- sence of prodromes, and, usually, of fever. They are also mostly partial and without the history, course, or results of scarlatina ; but at times, and especially when they follow the ingestion of preparations of cinchona, the whole complex of scarlatinal symptoms may be accu- rately simulated. The conditions for diagnosis have already been pointed out. In second or repeated attacks of so-called scarlatina, due consideration of the possible influence of drugs as an etiological factor will doubtless convert some very puzzling cases into very simple ones. Acute exfoliative dermatitis and desquamative scarla- tiniform erythema 68 may well be mistaken for scarlatina upon their first appearance. The rash is more protracted than in the essential fever, and is less abrupt in its onset. The local symptoms are very marked, while the constitu- tional phenomena are usually insignificant. The desqua- mation may begin while the eruption is in full flores- cence. These affections are not contagious and have no specific sequelae. An erysipelatous eruption may be like that of scarla- tina. It, however, differs markedly in its distribution, its evolution, and its course, being never universal, always progressive, and of indefinite duration. The subjective symptoms are quite different in the two affections ; the erysipelatous eruption is painful both spontaneously and on pressure. Much oedema accompanies the latter erup- tion. Diphtheria may complicate scarlatina, and the inten- sity of the local inflammation may induce a coagulation necrosis exactly corresponding to the membranous for- mations of diphtheria. Idiopathic diphtheria may espe- cially resemble scarlet fever when it is accompanied by the erythematous exanthem that is sometimes developed, either early in the disorder or later, in cases of blood poisoning. At first it may not be possible, to arrive at a correct diagnosis. According to Robinson, 69 in the early diphtheritic erythema there is no marked elevation of temperature. The rash may begin in any region, and rarely extends to the whole surface. The tongue is not affected, and there may be no special general disturbance. Desquamation does not occur. Bacteriological examina- tion of the nasal and buccal secretions will almost always determine the presence or absence of true diphtheria. The late diphtheritic erythema is septic. When the eruption of scarlatina is imperfectly devel- oped, or when it does not appear at all, and when sore throat and fever are the only symptoms to attract atten- tion, the diagnosis must rest upon the history of the patient and his surroundings, and upon the course of his illness. In not a few cases a retrospective diagnosis of scarlatina must be made, after the occurrence of desqua- mation or the supervention of nephritis and dropsy un- der conditions that indicate their scarlatinal origin. Pkognosis. — The mortality from scarlet fever varies widely in different epidemics. Prom the affection that in Sydenham's time "hardly deserved the name of disease " to a pestilence of intense malignity, all degrees of fatality have been, and continue to be, observed. Epidemics have been recorded in which no deaths have occurred. Recently Whitla ™ has recorded but a single death in 133 cases of scarlatina treated in hospital. Such results are, unhappily, exceptional. The mortality has been known to Teach 30 and 40 per cent. An excessively high rate of mortality is, in great part, attributable to epidemic 62 tendencies toward grave complications, diphtheria, ne- phritis, etc. In private practice the death rate will not often exceed 10 per cent. In hospitals the percentage of deaths is usually much higher, the result being due to the fact that milder cases are kept at home for the most part, and not to differences in social condition, except in so far as neglect and exposure previous to admission may have aggravated an attack or have excited a complica- tion. The death rate will be high or low in accordance with the type of the prevailing epidemic, and the aver- age mortality of the disease should always be considered with reference to this. Neither season nor atmospheric condition appears to exert any influence upon the epi- demic type. Likewise, telluric conditions do not modify it. Benign and malignant epidemics follow each other without evident cause. The mortality at the beginning and during the height of an epidemic is greater than dur- ing its decline. Barring the effects of extreme poverty and exposure, scarlet fever affects the rich and poor impartially. The sexes are almost equally attacked, but age exerts a striking influence upon the result. Children under one year of age, though less apt to be attacked, are especially liable to fatal forms of the disease. Ac- cording to Fle'ischmann, the mortality at St.' Joseph's Hospital was: under one year of age, 75 per cent. (8 cases, 6 deaths) ; from one to four years of age, 43 per cent. ; from five to twelve years of age, 19.6 per cent. ; the total mortality being 10 per cent. The majority of deaths occur under the sixth year of age ; with increasing years the prognosis becomes more favorable. Fleisch- mann's records show a j higher mortality than those of some other writers. For example, Kraus gives 4 deaths in 13 cases less than one year of age; 29 deaths in 113 cases from the close of the first to the close of the fifth year of life ; 10 deaths in 106 cases from the end of the fifth "to the close of the twelfth year of age ; and 2 deaths in 40 cases from the twelfth to the twentieth year of age. Voit reported 1 death in 5 cases less than one year of age ; 24 deaths in 166 cases from the first to the close of the sixth year of age ; 10 deaths in 109 cases from the sixth to the twelfth year of age. Roset reported 16 deaths in 43 cases less than one year of age ; 31 deaths in 156 cases from the first to the close of the fifth year of age; and 3 deaths in 88 cases over five years of age. 11 An exception must be noted to the favorableness of the prognosis in persons of maturer years, in the case of puerperal women, in whom scarlatina has already been shown to be espe- cially malignant. No case can appear to be so mild as to justify a prognosis unqualifiedly favorable. From the beginning until the termination in recovery there is no period when a sudden change may not place the life of the patient in jeopardy, whether by an aggravation of the essential symptoms of the disease, or by the superven- tion of complications. The prognosis, however, is gen- erally favorable if the disease pursues a regular course ; if the eruption follows a brief prodromal stage and is regularly developed; if the fever, more or less intense from the first, does not exceed at the height of the erup- tion 40° C. (104° F.), and, steadily falling, reaches the normal on the sixth, seventh, or eighth day ; if the an- gina do not assume a diphtheritic character, and is not complicated by parenchymatous tonsillitis, retropharyn- geal abscess, or cellulitis of the throat or neck; if the kidneys remain unaffected or show only slight evidences of disorder. On the other hand, the prognosis is more grave when the eruption appears after a prolonged pro- dromal stage, or when the attack is ushered in by con- vulsions or other profound nervous disturbance; or when the temperature reaches a high degree, 40.6° to 41° C. (105° to 106° F.), at once; or when intractable vomiting is present ; or when diarrhoea is a prominent feature ; or when the pulse beats more than one hundred and twenty times to the minute, and is feeble, unequal, and irreg- ular; or when the throat is ulcerated and develops diph- theritic inflammation; or when suppurative, parenchy- matous, or gangrenous inflammation of the tonsils, or retropharyngeal abscess supervenes ; or when the neck becomes swollen, brawny, and livid from glandular, peri- REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. Scarlet Fever, Scarlet Fever. glandular, and diffuse cellular inflammation. Apprehen- sion should always be excited if the eruption come out imperfectly or irregularly while the fever is intense ; or if, once fully developed, it suddenly fade; or if the eruption assume a livid color or a distinctly hemorrhagic character. A coppery hue of the eruption is unfavor- able, as is also a livid coloration of parts not invaded by the eruption. Small, scattered petechia? in the midst o'f an otherwise normal eruption are unimportant. Miliary vesicles, developing in the ordinary course of the fever are insignificant; occurring later, during an attack of unusual severity, they are often the forerunners of death. Convulsions first occurring after the height of the fever are more ominous than if occurring earlier. Should the eruption, and especially the fever, continue unabated after the usual period, dangerous complications are to be apprehended. Coma is of grave augury, as indicating uraemia, oedema of the brain, or even meningitis. Ne- phritis is more serious the earlier it is developed. It oc- casionally happens that scarlet fever at first shows the symptoms of a mild attack, but, before the completion of the eruption, asstimes a malignant character. If symp- toms of malignancy occur after the completion of the eruption, they are usually attributable to complications. On the other hand, all the signs of malignant scarlatina may be present at the outset. High fever, rapid pulse, convulsions or coma, protracted vomiting, intense erup- tion, may all yield after the second or third day, the dis- ease thenceforward pursuing a mild course; again, symp- toms of malignancy may disappear upon the supervention of a delayed eruption. Mayer ,s observed a temperature of 43° C. (109.4° F.) on the evening of the second day. The temperature subsequently varied slightly until the fourth day, when, upon the appearance of the eruption, it subsided. The occurrence of scarlatinal diphtheria always increases the danger of death. Heubner regards its sudden extension to the soft palate and to the portals of the oesophagus and trachea as certainly to be followed by death within from twenty-four to forty -eight hours, the fatal issue occurring either through gradual progress of gangrene, by inflammation of the lymphatic glands and connective tissue of the throat and neck, or by oedema glottidis. When circumscribed spots are invaded and the lateral portion of one tonsil shows the first patch, from which the membrane gradually spreads, recovery may occur. Diarrhoea persisting during the attack greatly increases the danger. Nephritis is always a serious com- plication, though terminating favorably in most cases. The danger is usually proportionate to the earliness of its occurrence. Death may occur as in ordinary nephritic inflammation. Scarlatinal nephritis most rarely becomes chronic. Inflammation of the organs of hearing, while rarely imperilling life, often results in partial or com- plete deafness. This, according to Burkhardt-Merian,™ depends upon croupous-diphtheritic inflammation pri- mary in the throat. The prognosis is more unfavorable if the process be allowed to go untreated. Rheumatic and rheumatoid inflammations are not commonly dan- gerous complications. Endo- and pericarditis, pleurisy, peritonitis, meningitis, pneumonia, dysentery, parenchy- matous degeneration of the heart, 'etc., are all compli- cations of extreme danger. Purulent inflammations of pyemic origin usually constitute sequel® of scarlatina, and are of the gravest importance. Treatment. — Mild cases of scarlatina require little more than good nursing, the regulation of the diet, and proper precautions against the spread of the disease to the other members of the household. Severe cases, on the contrary, tax the resources of the physician to his utmost. General Principles of Prophylaxis, Hygiene, and Disin- fection. — As soon as the disease is recognized the patient should be removed to a clean, well-ventilated room, pref- erably at the top of the house, and accessible by way of back stairs, and all persons not concerned in the care of the patient should be rigidly excluded. The following practical rules and directions, taken in part from those issued by the New York Board of Health, for the prevention of the spread of the disease in a family in which one case exists, cover in a general way the matter of prophylaxis and disinfection. They should be followed as closely as possible, but at times may be modified to suit the requirements of the case. A copy should be given to the nurse and parents at the begin- ning of the quarantine, and they should be instructed to study the principles on which the directions are based in order that they may know how to meet conditions which are constantly arising in the course of the disease and which cannot be specially mentioned in directions in- tended for general use. 1. If possible one attendant should take the entire charge of the sick person, and no one else besides the phy- sician and nurses should be allowed to enter the sick- room. The attendant should have no communication with the rest of the family. While in the sick-room she should wear a covering to protect her hair, and a gown, which should be removed when she leaves the room. When leaving the portion of the house which is quaran- tined she should change her shoes, and dress and disinfect her hands and face, and should make use of the back stairs, so far as possible in going in and out of the house. The members of the family should not receive or make visits during the illness. Other children in the family should not be allowed to go to school, if they remain in the infected house, and if sent away they should be kept from other children until the stage of incubation has passed. The physician should exercise great care not to carry the contagious elements to other patients. Disre- gard of such precaution by many physicians is a fault only too common, and one which deserves the most severe condemnation. A cap covering the head and back of the head, a gown reaching from the neck to the floor, and rubber overshoes should always be put on before entering thepatient'sroom. When these are removed, they should be dipped in carbolic acid or corrosive sublimate solution, and hung up to dry in an ante-room, where they will be ready for use on the following day. Rubber gloves are also a useful addition to the articles just mentioned. 2. The discharges from the nose and mouth must be received on handkerchiefs or cloths, which should at once be immersed in a carbolic solution (made by dissolving six ounces of pure carbolic acid in one gallon of hot water, which may be diluted with an equal quantity of water). All handkerchiefs, cloths, towels, napkins, bed linen, personal clothing, night clothes, etc., that have come in contact in any way with the sick person, after use should immediately be immersed without removal from the room in the above solution. These should be soaked for two or three hours and then boiled in water or soapsuds for one hour. They should be laundried separately from the household articles. 3. Great care should be taken, in making applications to the throat and nose, that the discharges from them in the act of coughing are not thrown into the face or on the clothing of the person making the applications, as in this way the disease is likely to be caught. 4. The hands of the attendant should always be thor- oughly disinfected by washing in carbolic solution, and then in soapsuds, after making applications to the throat and nose, and before eating. Rubber gloves may be worn with advantage while handling the patient. 5. Surfaces of any kind soiled by discharges should be immediately flooded with the carbolic solution. 6. Plates, cups, glasses, knives, forks, spoons, etc., used by the sick person for eating and drinking must be kept for his especial use, and under no circumstances be removed from the sick-room nor mixed with similar utensils used by others, but must be washed in the room in the carbolic solution and then in hot soapsuds. After use the soapsuds should be thrown into the water-closet, and the vessel which contained it should be washed in the carbolic solution. 7. The room occupied by the sick person should be thoroughly aired several times daily, and swept fre- quently, after scattering wet newspapers, sawdust, or tea leaves on the floor to prevent the dust from rising. Af- 63 Scarlet Fever. Scarlet Fever. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ter sweeping, the dust upon the woodwork and furniture should be removed with damp cloths. The sweepings should be burned and the clothes soaked in the carbolic solution. In cold weather the sick person should be pro- tected from the draughts of air by a sheet or blanket thrown over his head while the room is being aired. In summer the windows should be kept open sufficiently to secure free movement of air and agreeable temperature ; in winter an open wood or coal fire should be kept con- stantly burning. The temperature of the room should not exceed 21° C. (70° F.) nor fall below 18° C. (65° F.). The patient should be kept in bed even during the mild- est attacks, with only enough bed covering to secure comfort. 8. When the contagious nature of the disease is recog- nized within a short time after the beginning of the ill- ness it is advised that all articles of furniture not neces- sary for immediate use in the care of the sick person, especially upholstered furniture, carpets, and curtains, should be removed from the sick-room. If the disease is well advanced this should not be done without first taking precaution to disinfect them properly. 9. "When the patient is beginning to recover and the skin is peeling off, the body should be washed once daily in warm soapsuds, and afterward rubbed in oil or ear- bolated vaseline. This should be continued until all roughness of the skin has disappeared. 10. When the patient has recovered and the Board of Health inspector has authorized his discharge, the entire body should be bathed and the hair washed with hot soapsuds, the nose, mouth, and ears should be disinfected as far as practicable with antiseptic sprays, and a cor- rosive sponge bath of 1 to 2,000 to 1 to 5,000, according to the age of the patient, should be given. The patient should then be dressed in clean clothes (which have not been in the room during the sickness) and removed from the room. The Health Department should be immediately noti- fied, and disinfectors will be sent to disinfect the room, bedding, clothing, etc., and under no conditions should it be again entered or occupied until it has been thor- oughly disinfected. Nothing used in the room during the sickness should be removed until this has been done. 11. The attendant or any one who has assisted in car- ing for the sick person should also take a bath, wash the hair, and put on clean clothes, before mingling with the family or other people, after the recovery of the patient. The clothes worn in the sick-room should be left there, to be disinfected with the room and its contents by the Health Department. 12. As contagion sometimes occurs after very prolonged intervals it is generally better to observe the rule that isolation should be practised until the completion of des- quamation. Ashby 16 lays down the following rules in reference to the discharge of a scarlet-fever patient from quarantine. (1) If desquamation is complete scarlet- fever cases may be discharged at the end of the sixth week, although in order to secure absolute immunity it is wiser to delay until the eighth. (2) Cases complicated with nephritis, empyema, otitis, or glandular abscess, should be detained until the cure is completed. (3) While it is important that the desquamation should be as complete as possible, the detention of the patients be- yond the eighth week in order that the last vestige of epidermis should be removed from the feet, etc., is un- necessary. Such detention is, however, often insisted upon by health authorities. 13. The uses of belladonna and other " specifics " as a means of prophylaxis are based upon untenable hypoth- eses. Scarlet fever often fails to spread even when a number of persons have been exposed and the danger of drawing incorrect conclusions from the use of drugs as prophylactics is very great. The following are the best-known disinfectants : Heat. — Continued high temperatures destroy all forms of life. Boiling for at least one-half hour will destroy all disease germs. Carbolic Acid. — A standard solution is composed of six ounces of carbolic acid dissolved in one gallon of hot water. This makes approximately a five-per-cent. solu- tion of carbolic acid. The commercial colored impure carbolic acid will not answer for this purpose. Great care must be taken that pure acid does not come in con- tact with the skin. When practicable, the carbolic solution should be used as hot as possible. The cost of carbolic acid is much greater than that of the other solu- tions, but generally is much to be preferred. When the cost is an important element, the bichloride solution may be substituted for all purposes for which carbolic is rec- ommended, excepting for the disinfection of the dis- charges, eating utensils, or articles made of metal, and of clothing and bedding, etc., which is very much soiled; Its poisonous character, except for external use, must be kept constantly in mind. Corrosive Sublimate (bichloride of mercury). — A stand- ard solution is composed of sixty grains of pulverized corrosive sublimate and sixt3 r grains of the chloride of ammonia, dissolved in one gallon of water. This solu- tion must be kept in glass, earthen, or wooden vessels (not in metal vessels). The above solutions are very poisonous when taken by mouth, but are harmless when used externally. Milk of Lime. — A standard solution is made by mixing one quart of dry freshly slaked lime with five quarts of water. Lime is slaked by pouring a small quantity of water on a lump of quicklime. The lime becomes hot, crumbles, and as the slaking is completed a white dry powder results. The powder is used to make the solu- tion. Air-slaked lime has no value as a disinfectant. Formaldehyde. — The use of formaldehyde gas for dis- infection of rooms, clothing, and furniture, after the dis- charge of the patient, has now become general, and has proved superior to the older methods. The simplest, most convenient, and inexpensive apparatus for this purpose is the Schering lamp in which paraform pastils are burned, two pastils being used for each thirty-five cubic feet of air space. More powerful generators for the disinfection of very large areas are now commonly used by the Boards of Health, to whom the question of disinfection is generally referred. The proprietary disinfectants, often widely advertised, and whose composition is kept secret, are relatively ex- pensive and often unreliable and inefficient. It is impor- tant to remember that substances which destroy bad odors are not necessarily disinfectants. Diet. — The diet should consist in easily assimilable food; the nearer this approaches a pure milk diet the better. Cold drinks may be allowed; cold-water lem- onade, raspberry vinegar properly diluted, soda-water agreeably flavored, are grateful to the patient and pref- erable to warm and mucilaginous drinks. Though milk should form the principal article of food, light broths and soups, beef tea, chicken jelly, and, especially during convalescence, the various appetizing and wholesome preparations of food now so abundantly supplied may be given. Internal medication may be held in reserve, a careful observation of all symptoms being meanwhile maintained and the conditions of the kidneys systematically ascer- tained by daily observation. Hydrotherapy. —By far the safest and surest agent for reducing temperature in scarlatina is cold water which should always be tried before resorting to the use of anti- pyretic drugs, which are often dangerous, and the use of which should be discouraged. This may be applied in various ways. The simplest method is by frequent spongings with cold or tepid water under cover of the bedclothes. At the same time cold wet cloths may be applied to the head, and the patient may be permitted to suck small pieces of ice. In most cases it is better that the water be warm. The spongings may be repeated frequently during the day and night. In cases in which, with an elevated temperature, the eruption develops in- completely, or is much delayed in appearance, the body may be immersed in water somewhat cooler than its nor- mal temperature. A cool bath (27° C. = 80° F. ) has been 64 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Scarlet Fever. Scarlet Fever. extolled as of singular virtue in such cases, and at times it is of the highest value. The tepid, even the 'warm bath, is probably of equal benefit in most cases. Recent ■writers have denied that efforts to "bring out" an imper- fect or delayed scarlatina, eruption are of any avail. There can be no doubt, however, that treatment with this object in view is often successful. The hot bath, even with the addition of mustard, by exciting cutaneous hyperemia, will often relieve the congestion of internal parts. Warm and hot drinks made from various vege- table substances were formerly much employed to " bring out" the eruption. They were given copiously, and often in combination with such diaphoretics as spiritus mindereri, spirits of nitrous ether, etc. This plan of treatment is not much practised to-day. The cold bath, which should be of a temperature not lower than from 24° to 27° C. (75° to 80° F.), should be reserved for cases whose temperature exceeds 40° C. (104° F.). The body should be immersed but for an instant, the benefit of the plunge consisting largely in the dilatation of the vessels of the skin through reaction. The cold pack is also of value in these cases. When the temperature steadily rises to an alarming degree, or when hyperpyrexia is developed almost at the outset; when, with or without well-developed exanthem, stupor or coma, or other grave nervous disorder, arises, and when the pulse becomes very rapid, feeble, and irregular, the maintenance of life depends upon the reduction of temperature. Here it is impossible to give hard-and-fast rules for conduct. Water below the normal temperature of the body still remains our most efficient means of reducing the exces- sive heat. The lower the temperature of the bath, the more rapidly is this result attained, but the shock of the sudden contact with the cold water may exert a depress- ing effect that may not speedily pass off. The body can- not remain in very cold water longer than a minute or so without exciting chattering of the teeth, lividity about the mouth, and a pinched appearance of the feat- ures and of the surface. The warm bath (32°-35° C. = 90"-95° F.) has been highly extolled as favorably influ- encing the course of scarlet fever when used at the very beginning. Thompson employed it thus constantly, and never lost a case treated in this manner. In a bath of from 27°-30° C. (80° to 85° F.) the patient may remain for five or ten minutes. These baths should be repeated as often as the temperature of the body becomes as high as 39.5°-40° C. (103°-104° F.). To avoid alarming the little patient, the bathtub may be covered with a sheet or blanket. Placing him upon this, he may slowly be low- ered into the water. Upon removal from the bath the patient should be wrapped in a dry blanket. As the body soon dries under the protection afforded, rubbing with towels may be avoided. The skin should now be anointed with oil or other agreeable fatty substance. Re- freshing quiet and sleep often follow this bath. In us- ing the wet pack, a blanket may be spread upon a hard couch or bed covered with oil cloth ; upon this a sheet wrung out in cold water is laid. The naked patient is stretched upon this sheet, which along with the blanket is wrapped about him snugly. The brief sensation of chilliness is soon replaced by one of warmth, and after a few moments the body breaks out into copious perspira- tion. This may be encouraged by hot drinks, and hot bottles to the surface. The patient should not remain too long in the pack, otherwise hyperpyrexia may rather be increased than diminished. In the intervals between the baths, in extreme cases in adults, an ice cap may be worn, and cloths wrung out in iced water may be applied to the epigastrium. The application of ice to the head in the case of infants and young children is, however, a dangerous practice owing to its depressing influence, and should rarely, if ever, be resorted to. Nothing can exceed the efficacy of the above-described method of treating scarlet fever with high temperature ; but to se- cure its full influence, it must be pursued systematically and intelligently. The thermometer must constantly direct the actions of the physician. The prejudices of friends and attendants against the immersion of the Vol. VII.— 5 fevered body in ice-cold water will not extend to the use of tepid and cool baths, from which, indeed, equally good results may be obtained. The baths may have to be repeated at intervals of two or three hours" for days before the fever begins to yield ; or they may unhappily altogether fail to control the irresistible intensity of the disease. On the other hand, they frequently exert a most gratifying influence upon the course of the malady, the temperautre becoming permanently reduced, the pulse quieter, fuller, and regular; jactitation, delirium, and coma being replaced by composure, consciousness, or natural sleep. Often an attack that appeared about to pursue a malignant course, under the influence of the bath becomes benign and terminates favorably. While exalted temperature that threatens to destroy life can, in the manner indicated, often be reduced, the course of the disease itself cannot be aborted. No remedy is known that can be said to exert a specific influence over it. Vaunted specifics have not withstood the test of ex- perience. Medicinal Treatment. — Probably the most popular rou- tine treatment of ordinary scarlet fever is that of car- bonate of ammonia. When in cases of very elevated temperature the heart action flags, the pulse becoming rapid, feeble, and unequal, when delirium or stupor ap- pears, the preparations of ammonia are demanded. The carbonate, in doses of one to three grains to a child five years of age, may be given ever}' third hour in aqueous solution with milk, which in a great measure destroys the pungent, disagreeable taste ; or it may be given in solution of the acetate of ammonia, a most commendable combination. The aromatic spirits of ammonia may be employed for the same purpose. Hoffman's anodyne, whiskey, or brandy is especially indicated when the ner- vous system shows alarming signs of perturbation, delir- ium, jactitation, stupor, etc. When strong cardiac stim- ulants are demanded, the fluid extract of digitalis in one-minim doses, for a child of five years, or strychnine in doses of gr. ^hs *° S r - t'tt> should be given. Caffeine and camphor are also of use as adjuvants to the cardiac stimulants already mentioned. Purgation, which should usually be avoided, may at times become necessary. Small doses of calomel (gr. £ to gr. J) repeated every hour until the bowels are moved, generally act well. Castor oil is a harmless and safe, but nauseous agent. Rhubarb and scammony are also efficient cathartics; either may be given in doses of five 'grains to a child six years of age. When depression is profound, reliance should be placed on enemata in preference to active cathartics. During the progress of the disease the expectant plan of treatment is most to be recommended. The daily bath or sponging should be continued. It is probable that renal complications are thus frequently avoided. The patient should be jealously guarded from draughts and dampness, and even the mildest cases should be kept in bed for at least ten days after the cessation of fever ; nor should the patient be allowed to leave his room before the expiration of the third week. Out-of-door exercise cannot be resumed in disregard of season, or of barome- tric and thermometric variations. In midsummer, when windows and doors must remain open, the question of out-of-door exercise is rather one of danger to others than of personal risk; while in spring, autumn, and winter the risks of exposure are especially great. During these seasons the patient should not venture into the open air before the sixth or seventh week of perfectly normal scarlatina. During convalescence the daily baths should be continued until desquamation is completed, and daily inunctions with mild antiseptic ointments, such as car- bolated vaseline or boracic ointment, will both expedite this process and minimize the dangers of contagion. No further medication besides an appropriate tonic will be required. Nasopharynx. — If the aiigina does not exceed a simple hyperemia, mild alkaline antiseptic sprays applied fre- quently to the nose and throat by means of an atomizer are all that are required. If the patient is young and 65 Scarlet Fever.' Scarlet Fever. 1 REFERENCE 1 HANDBOOK OF' 'THE MEDICAL SCIENCES.; resists vigorously this treatment, it should riot* beeper-, sisted in. If the nasal discharge is profuse and purulent,' gentle syringing with such' solutions as Dobell's, Seiler s, andalcohol is indicated. Should the throat develop 'the whitish curdy deposits of follicular inflammation and the erosions that so often accompany acute catarrhal pharyn- gitis, an antiseptic gargle will act beneficially and will Correct foetor of breath, and to some extent disinfect the secretions andexhalations. For this purpose one of the subjoined prescriptions niay be employed : 1$ Acid, carbolic, cryst 3 ss. Glyceriri. ......... i f. 3 1. Aq. destil,. q.s. ad f. 3 vi. M. Sig. : Use as a gargle or spray. Or , Ij, Tinct. ferri chlorid >. •. . f . 3 i- Potass, chloral-. .; > ;. 3 ss._ Glycerin '. f . 3 i. Aq. destil, q.s. ad. f. S viij. ' M. Sig. : Use as a gargle or spray. When .the inflammation is more severe, and accom- panied by more or less superficial ulceration, applications should- be made with. a probang-or camel's-hair pencil. When the surface is foul and covered with offensive. ex i udation, an excellent application' is' the following, first recommended by J. Lewis Smith: $ Acid, carbolic., .... ..'.,. • . . . .'. gr. lij.-vi.. Liquor ferri subsulphat., . : f. 3 ij. Glycerin ...... :.'.;. ..'. ' f. 3 vi. M. Sig. : Apply With:a brush three or four times a day. ' Or the following: / ^ Tinct. iodinii...'. .'.'..: f. 3.^ Glycerin ..:....... t f . 3 vij. Diphtheritic inflammation, if associated with the pres 7 fence of the: Klebs-Loeffler bacillus, calls for the treatment with the antitoxin of diphtheria, in addition to the' local treatment of. the nose and throat by sprays and gargles; \ Cauterization with silver nitrate, acid nitrate of mereury, chromic acid, or other agents should not be practised. , Tracheotomy should never be performed. A case oif scarlatinal diphtheria whieh presents the symptoms which demand this Operation,; in the idiopathic disorder, is beyond the resources! of surgical art. . ', i ;.' Lymph Nodes.— Inflammation of the lymph' nodes of the neckandof the.adjaeent connective tissue, may be treated first by inunction of oil or cerate. In severer forms an ice 'bag, and when suppuration ! threatens, creolin or ■flaxseed poultices should be. applied. Points at which suppufatiori , appears should be incised early and freely to prevent burrowing-. Gangrenous inflammation may sometimes.be. arrested by strong 'caustics. Iron, qui- nine, stimulants, and nourishing and supporting food should, be administered in, these conditions with a, free hand, but always with care not to derange the digestion of the patient. , i Ba/r. — Scarlatinal aural inflammation calls for special ', treatment, and whenever possible it should be referred to , the aurist. The nasal douche should be used and the i diphtheritic' pharyngeal and nasal cavities should be re- peatedly syringed with antiseptic solutions, for it is by 'the extension of the inflammation along the Eustachian 'tube that the severer forms originate. When the aural inflammation is established, inunctions of mercurial oint- ment, or of the oleate of mercury, or of iodoform oint- ment, should be made about the ear several times daily. When the tympanic membrane becomes strongly injected and bulges outward, paracentesis for the release of the [ pent-up exudation should be performed. Timely tap- ping of this membrane will often preserve the imperilled sense of hearing. This operation is especially commended iby Buck arid Olshausen. It is simple and very easijy .'performed. The sensitiveness of the membrane may be obtuoded to a slight! degree by the instillation of a four*, per-cent. solution of muriate of cocaine. Porneroy'sdirec-i tions for performing the operation are as follows: "A good-sized speculum is introduced into' the meatus. Then- ah ordinary broad needle, about One line in diameter,, with] a shank of about two inches, such as oculists use for punct; uring the cornea, Should be held between the thumb awl. fingers, lightly pressed so as not to dull delicate, tactile, sensibility., The part being well under light, the mostj bulging portion of, the membrane should be lightly and quickly punctured with a very slight amount of force.! The posterior and superior portion of the membrane is, most likely to bulge. The chorda tympani nerve usually, lies too high up to be wounded. The ossicles are avoided by selecting a. posterior portion of tb/3 membrane. After, puncture the ear should be inflated by an ear-bag whose nozzle is inserted into a nostril, both nostrils, being closed,- so as to force the fluid from the tympanum. The punct- ure may need to be repeated at intervals of a day or two, provided that the pain and bulging return.""! When pain and tenderness only are present, hot fomeni tations to the external ear, and ,to the parotid and mas- toid regions, are Yery soothing. Laudanum and swee$ oil, of a two- to four-per-cent. solution of sulphate of atropine instilled warm into the external meatus, often give relief. ' Frequently renewed solutions of cocaine are very efficacious. Bags of hot table salt, or of heated flowers of hops, are well-known domestic remedies, When perforation occurs spontaneously the hearing rrifijf be preserved, but partial deafness is often permanently established, and sometimes the sense of hearing is totally abolished. In such cases the ear should be frequently syringed with Warm water, or with warm solutions of boracicacid followed by insufflations of boracic-acid powr der. Granulations and polypi developing in the cours? of chronic otitis may be benefited and even cured by as T tringent powders and washes. Surgical interference will at times be necessary. ' : Mephrilw— When nephritis arises in theconrseof scar 7 let fever; or as a sequel, prompt measures for its relief must be adopted. Where it forms a feature of rapidly fatal malignant scarlatina, it may have no time to des- velop Symptoms, or these may escape detection,' or the virulence , of the disease may throw the renal disorder into the background, or render attempts to treat it-futile. In milder cases, and later, during the latter part of the first or during the Second or third week, especial atten- tion may. be devoted ,to the treatment; of nephritis,. Slight; albuminuria will' occur, according toj Mahomed, during convalescence, associated! with constipation -and a hard pulse,' indicative of [high arterial [tension, without subjective Symptoms, and remediable by a brisk purge;. This. authoralso asserts that a slight chillingof the sur- face is sufficient to cause transitory albuminuria. ;The patient should therefore be carefully protected, in thp manner already indicated. , Dietary management will gp far toward preventing renal complications, A rigid milk diet; in all cases of scarlatina; is regarded by Jaccoud as absolutely preventive of nephritis. Though this may be an extravagant statement, it is certain that in scarlatina there is no better diet than one of milk. Should nephri- tis arise, it is the more important that the milk diet should be continued. From two to three or four : pints may bp given during the twenty-four hours, in small quantities., at brief intervals, the latter amount being sufficient for an adult without other -food. If there are reasons why milk cannot be taken, light broths and squpsand chicken jelly may be substituted, together with light farinaceous food. Buttermilk may at times be preferred, and bonny-clabber and slip or junket (milk sweetened and flavored and coagulated with liquid rennet) are often relished, and are excellent articles of food, Proper re- gard having been paid to the hygienic surroundings and nutrition of the patient, a brisk hydi>agogue cathartic should be administered, unless diarrhoea be; already pres- ent. For this purpose there is nothing better than the compound jalap powder, For a child, from five tp ; twenty grains of this should be ordered every night; as 66 REFERENCE HANDBOOK OF THE MEDICAL' SCIENCES. Searlet Fever. Scarlet Fever, required, the object being to secure several watery actions of the bowels every twenty -four hours. The proper dose for an adult is one drachm. The desired watery stools may also be readily secured by the saline cathartics if given in concentrated watery solution. The more drastic purgatives will rarely be required, except in uraemic intoxication and in extreme dropsy, when podophyllin, croton oil, elaterin, etc., may occasionally be employed with benefit. When dropsy is but slightly pronounced, purgation may not be required. The action of the skin should next demand attention. Frequently during the day the body may be wrapped in flannels, wet or dry, as hot as can be borne; or the wet pack may be applied. When available, the steam bath or hot-air bath is to be strongly recommended. The hot plunge bath may also be employed most advantageously. Pilz has especially lauded this treatment. It should be used after the method of Liebermeister, by gradually in- creasing the temperature of the bath from 36° C. to 40° C. (96° to 104° F.), in a half-hour. Under its daily use dropsy speedily disappears. Diseases of the heart and lungs, while not positively contraindicating this plan of treatment, necessitate great caution in its application. Sudden chilling of the surface after the bath should be avoided. The imminence of the danger is usually pro- portionate to the degree of impairment of the function of the kidneys. In giving remedies to modify their action, none calculated to increase their hy persemia should be employed. Exception can hardly be made in favor of juniper, which enjoys with some writers considerable reputation in scarlatinal nephritis, and digitalis has re- ceived very general approval as a most useful diuretic in acute nephritis. From one fluidrachm to a half fluid- ounce of the infusion (which is much the best preparation for the production of diuresis) may be giveu three or four times daily, the dose varying with the age of the patient. Its effects, however, are hardly as happy as when dropsy is associated with, or dependent upon, cardiac weakness. Diuretics that act specifically upon the secreting cells of the urinary tubules, the sedative or refrigerating diuretics, are to be preferred, as a rule, in the treatment of scarlat- inal nephritis, and will often achieve most astonishing results. Of these the salts of potash are most efficacious — the citrate, the acetate, the bitartrate, and the bicar- bonate. For slight nephritis and anasarca a lemonade made with bitartrate of potash will be taken with avidity, and will often almost magically increase the quantity of urine, reduce the dropsy, rapidly diminish the albumi- nuria, and cause a radical change for the better. Diuretin in five- to ten-grain doses may be combined with this with great advantage. This lemonade may be made by adding one drachm of cream of tartar to a pint of boiling water, into which a sliced lemon has been dropped. This quan- tity, properly sweetened, may be drunk during the day by a child five years of age. Water may be allowed freely, or any of the mild domestic infusions may be sub- stituted for it, their virtue residing principally in the amount of fluid. The free use of water is especially to be recommended as unirritating, and tending to wash out of the tubules the exudate choking up their lumina. In more severe cases, where life is threatened through one or an- other form of uraemia, very energetic treatment will be required. Jaborandi may now prove useful. J. Lewis Smith, Hirschfeld, and others have commended its action highly. For a child two years of age, one-twentieth of a grain of pilocarpine may be given by the mouth every fourth or sixth hour, or the same amount may be in- jected hypodermically, and prove much more efficient. Both diuresis and diaphoresis will be promptly increased, and in favorble cases the urcemic symptoms will disap- pear. Hot saline injections, given by rectum aDd re- peated several times a day are frequently of value in threatened uraemia. Uraemic coma and convulsions, de- veloping suddenly or after progressive renal embarrass- ment, should be treated without reference to the scarla- tina and upon general principles. A remedy of most undoubted value, at least for the control of convulsions, is chloral, which, if the patient be unable to swallow, may be injected in full dosea under the skin or into the rectum. After the more acute nephritis has subsided and con valescence promises to become established, iron becomes one of our main reliances, in virtue of . its, combined . haematic and diuretic properties. The MistuijaJ.ferri et ammoniaa acetatis will generally be found to be'the best ', of the old preparations. Recently many new and excel- lent preparations of iron in organic combination have been put upon the market. Quinine is also a remedy of great value in the treatment of convalescence from scar- latinal nephritis. During the height of the inflammation, local treatment is often of great importance. If fever is. intense, the pulse full and strong, and if pain and ten- derness in the back are pronounced, the abstraction of blood, by leeches or cups, from the loins will often prove beneficial. Large sinapisms and poultices may be ap- plied over the kidneys. Besides assuaging the irritation they tend to promote diuresis and diaphoresis. .For ob- vious reasons, turpentine should not be employed as a counter-irritant in these cases. Ascites may occasionally be so excessive that the pressure exerted upon the kid- neys interferes with the action of therapeutic agents, and impedes the functional activity of these organs. Para- centesis abdominis, by relieving this compression, will often be followed by copious diuresis and the rapid dis- appearance of general anasarca. Cases of scarlatinal, nephritis which pass into chronic Bright's disease, as rarely happens, will require the treatment appropriate for this condition. During convalescence the usual pre- cautions will be necessary. The treatment of other com- plications and sequelae of scarlet fever is not peculiar, and will require no special notice here. Serotherapy. — In 1896 Josias, of the Trousseau Hospi- tal, gave an account of the treatment of a case of scarla- tina with Marmorek's antistreptococcus serum. The results apparently were inconclusive, and subsequent trials by other investigators have proved equally so. Quite recently the efforts to secure a specific antitoxic serum for scarlatina have received a new impetus, and have given rise to much discussion. Baginsky, of Berlin, claims to be the first to call atten- tion to the association of a streptococcus with scarlet fever, and he has announced that Dr. Aronson has demon strated an anti-scarlet-fever serum, which, as he believes, will prove specific in this disease. Priority is : disputed by Moser, 63 who asserts that, with Pirquet, he previ- ously had shown this association, which was also inde- pendently found by Salge as a result of agglutinating reactions, the peculiarity of which was first demonstrated by van de Velde and Paltauf. The first antistrepto- coccus serum, he says, was produced by Marmorek, and Aronson's was perfected on similar lines, while his own is based on different principles. Aronson's test com- prises a macroscopic, and not the microscopic agglu- tination reaction on the peculiarity of which Moser bases his claims of priority. Out of ninety -nine cases of fatal scarlatina, Moser has been able to cultivate u - 85 strep- tococci from the blood in the heart in sixty-three cases. These results accord with those of previous investiga- tions, and make it probable that streptococci play an im- portant part in the disease. On the other hand, the use of ordinary antistreptococcus serum has not proved of use in treating the disease. Moser points out that this may be due to the fact that there are different varieties of streptococci. The organism isolated from scarlatina differs from other varieties found in other diseases, in being almost innocuous for rabbits, and in possessing different agglutinating properties. Moser therefore pre- pared a special immune serum from streptococci obtained from scarlet-fever cases. As there is no proof yet that the organism is the same in all cases, he produced a polyvalent serum by injecting horses with increasing doses of the mixture of living cultures obtained from dif- ferent cases of scarlet fever. The organisms were grown on bouillon, and were not passed through animals. After months of such treatment the serum was drawn off and preserved in a sterile condition, without any addition of 67 Schoenlein's Disease. Scbool Hygiene. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. -a preservative. The serum was tried ineighty-four cases. -M first the dose was too low. Later, better results we't'e obtained, doses of 180 c.c. being used. Possibly the serum was more potent in the later cases. The indi- vidual doses varied from 30 to 180 c.c. ; the latter amount is now chiefly used. In seventeen cases classed as mild or moderately severe, there was no mortality. In sixty- two cases classed as severe and apparently hopeless there we*e sixteen deaths. The earlier the injection the more iftCvorable is the result. The chief clinical result is the "rapid improvement in the general condition. With early injection the rash may not fully develop, or may fade much sooner than usual. The disturbances of the cen- tral nervous system disappear in a short time, while the temperature and pulse often show a critical fall. The symptoms of heart weakness are favorably influenced. The throat clears up more quickly, and although super- • flcial necrosis is not prevented, Moser has not observed deep destruction. As yet, nothing can be said about the effect of serum on the renal and middle-ear complications. The whole course of the disease is shortened, and conva- lescence occurs much sooner. Injections of normal horse serum had no effect on the course of the disease. Serum rashes were often noted, but joint pains and abscess for- mation were rarer. A much larger number of observa- tions must be made before a definite opinion can be held in regard to the efficacy of this form of serumtberapy in scarlatina. The results already attained certainly war- rant further investigation along the same or similar lines. Roger 81 attempted, in a single case, to treat scarlet fever by injecting into a vein 80 c.c. of serum taken from the blood of a patient recently convalescent from scarlet fever. The case was apparently comatose at the time of the experiment, and recovery took place, but no conclu- sion can be drawn from this single instance. Obviously it is not a method practicable for general use, and is only of scientific interest. Preventive Inoculation. — Stickler 86 in 1897 attempted to produce a mild type of scarlet fever by inoculating children with subcutaneous injections of mucus obtained from the throats of recent cases of scarlet fever. The results of the experiment showed that the symptoms pro- duced were practically as severe as those of the typical cases of scarlet fever, and that preventive inoculation on the principles of vaccination for the smallpox was im- practicable. Incidentally his experiments showed that the secretions of the mouth and pharynx of scarlet fever are highly virulent, as all the symptoms of scarlet fever appeared, with hardly any incubation period, within from two to twenty-four hours. 1. E. Atkinson. Revised by Maynard Ladd. I Historiscb-Geograph. Pathol., vol. 1., New Sydenham Soc. Trans- lation, p. 172. 2 Amer. Journ. of the Med. Sciences, October, 1855. 8 Jahrbuch f. Klnderhellk., 1870. 4 Hebra : Diseases of the Skin . New Syden. Soc. Translation, vol. i., p. 218. 8 Lancet. 1683, J., 194. « Ibid., 1885, i., 354. ' Ibid., 1883, 1., 685. 8 Rehm : Jahrb. f. Kinderheilk., 1869, 4. 8 Vol. xi., 1878. '» Zlernssen's Cyclop., vol. II., p. 169. II Jahrbuch fur Klnderhellk., 1875, viii. " Lancet, 1870. J9 Jahrbuch fur Kinderheilk., i., 1870. ■« Lite. cit. 46 Vierteljahr. f. Dermatol, u. Syph., vili.. 582. 16 Albuminuria, p. 320. " Jahrbuch fur Kinderheilk.. 1870, 411. " Gazette des Hdpitaux, 1885, lvlli., 418. 18 Berliner kiln. Wochenschr., 27, 1882. 2 » Ibid., 50, 1873. "" Correspondenzbl. f. Scbweizer Aerzte, No. 8, 1876. 22 Berliner kiln. Wochenschr., 8, 1882. 23 BurkhardMtferian : Volkmann's klin. Vortr&ge, 128, 1884. 24 Boston Med. and Surg. Journal, x., 228. 25 Gundrun : Med. News, 1882, xll., p. 231. 26 Baader : Loc. cit.— Hynes : Lancet, 11., 1870. 27 Deutsche med. Woch., x., 37-40. 28 Berliner klin. Wochenschr., 1868, No. 2. 2 » Ibid., 1868. No. 9. . 30 Jahrbuch fur Kinderheilk., 1872, v., 324. 31 The Practllioner, 1875, xvl., p. 21. " lancet, 1885, II., p. 795. 33 CharitC Annalen, 1876, lit, p. 538. 34 British Medical Journal, No. 498, 1870. 80 Robuske: Deutsche med. Woch., October 8th, 1881.— Mitchell : Edinburgh Med. Journ., February, 1882. 38 Deutsche med: Woch., 31, 1883. 87 Jahrbuch fur Kinderheilk., N. F., 1, p. 434. 38 Ibid., viii., H. 2, p. 15. 3 » I hid., N. F., 4, 1870. 40 Ibid., to., 166. ■ « L'Unlon m^dlcale, April 30th, 1882. 42 Wiener med. Wochenschr., 39, 1877. « Ibid., 43, 1877. 44 Deutsche med. Wochenschr., 31, 1883. ■" Berliner klin. Wochenschr., 43, 1883. 19 A Treatise on the Diseases of Infancy and Childhood, Philadel- phia, H. C. Lea. 47 Medical Record, 11., 1859. 48 Journ. of Cutan. and Venereal Diseases, vol. 1., 1883. 49 Clinical Lectures and Essays. 00 Guy's Hospital Reports, 1879. 51 Ibid. 62 Konetschke : Wien. med. Presse, 1882. xxili., 1483 : Ffolliott : Brit. Med. Journ., I., 1879. «» British Med. Journ., 1879, ii., p. 75. 54 Amer. Journ. of the Med. Sci., lxxxvii., 1884. 88 Page : Lancet, 1885, i., 887. 68 Archiv f. Gynakologie, ix., Bd. 2, 1876. 57 Dublin Journal Medical Sciences, February, 1866. 68 Obstetrical Transactions, 1871, vol. xii., p. 58. 50 Berliner klin. Wochenschr., 47, 1872. See also Smith : Med. Times and Gaz., 1870, ii., 1053.— Schwarz : Wien. med. Wochenschr., 42, 1871.— Broadbent : Brit. Med. Journ., April 1st, 1876.— Barrs: Lancet, 1883, ii., p. 102.— Farrar : Lancet, 1875, i., p. 109. 60 Trojanowsky : Dorpat. med. Zeitschr., L, 1871. 61 Dorpat. Med. Zeitschr., ill., 1873. 62 Correspondenzbl. f. Schweizer Aerzte, No. 5, 1876. 83 L'Union medicate, 8, 1883. " Progres me'dlcal, 1880, 47. 38 Wiener med. Jahrb., 2 H., 1882. 68 Transact. Patholog. Soc, London, 1877, xxviii., p. 435. 67 Handbuch der path. Anat. 68 Brocq : Journ. Cutan. and Venereal Diseases, August, 1885. 89 Journ. Cutan. and Venereal Diseases, April, 1883. 78 Dublin Journ. Med. Sci., March, 1885. 71 J. Lewis Smith : Pepper's System, vol. i., p. 534. 72 Ann. de Mddecine d'Anvers, London Med. Bee., 1882, 52. 73 Volkmann's Sammlung kiln. Vortrage, No. 128, 1880. 74 J. Lewis Smith : Pepper's System of Medicine, vol. 1., p. 548. 76 British Medical Journal, 1886, ii., p. 813. 79 Class: Jour. Amer. Med. Assn., February 24th, 1900. 77 Rotch : Pediatrics, 1901. 76 Holt : Diseases of Infancy and Childhood, 1902. 79 Nothnagel's Encyclopedia of Practical Medicine, American edi- tion, 1902. 80 Pearce : Boston City Hospital Reports, 1899. 81 Kober: American Journal Medical Sciences, 1901. 82 Baginsky : Berliner klin. Woch., 27, 29, 1900. 83 Moser: Berliner klin. Woch., 48, 49, 1902. 84 Moser : Wien. klin. Woch., 41, 1902. 86 Moser : Jahrbuch fur Kinderheilk., 1903, 57, der dritten Folge, 7 Band, 1 Heft. 88 Stickler: Trans. Med. Soc, New Jersey, 1897. 87 Roger : Presse meU, 1896, iv., 425. SCHOENLEIN'S DISEASE.— See Morbus Maculosus Werllwfii. SCHOOLEY'S MOUNTAIN SPRINGS. — Morris County, New Jersey. Post-Office. — Schooley's Mountain. Hotel. Access.— Prom New York via the Delaware, Lacka- wanna and Western Railroad, to Hackettstown, thence three miles by stage to springs ; or viS the Central Rail- road of New Jersey to German Valley, thence two and one-half miles by stage ; from Philadelphia vifl the Phil- adelphia and Reading Railroad to German Valley, etc. Schooley's Mountain is a broad plateau in the northern part of New Jersey, 1,200 feet above tide water, over- looking the Musconetcong Valley on the north and Ger- man Valley on the south. The scenery in the vicinity is varied and picturesque, and the neighborhood abounds in beautiful walks, drives, landscapes, etc. Among the near-by points of interest are Lake Hopatcong, Budd's Lake, and the romantic Delaware Water Gap. The chalybeate spring, situated half a mile from the hotel (the Heath House), has enjoyed for many years a reputation as a ferruginous tonic. The analyses which have thus far been furnished are not entirely satisfactory. It is an established fact, however, that the iron is present in rela- tively small quantity. The waters are recommended in cases of general debility, and of torpor of the liver, and in renal and bladder disorders. At the Heath House is an- other spring, which has been analyzed by Prof. George H. Cook, State geologist. It appears from this analysis that the water is rich in mineral ingredients. Nevertheless, so far as we can learn, it is not used for medicinal pur- poses. The Heath House and cottages consist of several detached buildings, none of them over three stories in height, with accommodations for three hundred and fifty guests. They are situated in the midst of a beautiful lawn of twenty-five acres. It is stated that the tempera- lure here averages ten degrees lower during the nay, and from fifteen to twenty degrees lower during the night, than at New York or at Philadelphia. James K. 'Crook. SCHOOL HYGIENE— The physical conditions attend- ing the education of the child at school are quite as im- portant as his mental training. School hygiene embraces 68 REFERENCE HANDBOOK OF THE MEDICAL i SCIENCES: Schoenleinii* Disease. School Hygiene. all that pertains to the physical welfare of the child in the course of instruction, both subjectively and objecr tively, including his own. physical condition, and the ef- fects of his environment. That the subject is attracting increased attention is evident from the enactment of laws relating to the ventilation and sanitary condition of school-buildings, the restriction of contagious diseases among school-children, and the medical inspection of schools. About one -fifth of the entire population.;, is tinder instruction in the schools, either public or private, at a period of life when good health and its preservation are matters of the highest importance. ! School-Buildings. Selection of Site.— The site should be chosen with reference to the convenience of a majority of the population for whom the building is in- tended, having in view a reasonable probability of future increase. It should be well back from the street, and not on a main street or thoroughfare. The neighborhood of noxious and offensive, as well as noisy trades, should be avoided. Nor should it be near the line of a steam railway. Proximity to liquor saloons should be avoided. Fortunately in some States, a definite distance is pre- scribed for such nuisances, so far as proximity to school- houses is concerned. The location should not be overshadowed by a hill of greater height than the school-building, especially upon its western side. The size of the site, including the playgrounds, should be largely determined by the num- ber of pupils to be accommodated, a space of thirty square feet being desirable for each pupil. The site should be capable of thorough drainage, and should be graded to a higher level than that of the con tiguous streets. The soil of the immediate neighborhood should also be dry, and there should also be opportunity to obtain a supply of pure drinking-water. School-Building. — In the planning of school-houses, the school-room should be the unit first considered. Accord- ing to Shaw, "the school-building should be a number of Fig. 4167.— A Good Single Floor Plan. Rooms well arranged for seating and lighting. (Shaw's "School Hygiene," The Mac- millan Company school-rooms properly disposed, and not a whole cut up into school-rooms, whose size and arrangement are de- pendent upon the size and shape of the building." ■ The general shape of the school-room should be oblong, with the aisles running lengthwise of the room. This allows proper lighting of the desks (Fig. 4158). The question of the size of the school-room has re- ceived much attention, and has been made the subject of experiment until definite standards may now be recom- mended, depending upon the ventilation, heating, light- ing, and (tfoei needs of the eye and ear of the.ipupil, A minimum of 15 square feet of floor .apace and .200 cubic- feet of air space for each pupil should be insisted; upon. For a room intended ifor forty-eight, pupils these condi tions may be secured with a height. iof 13 feet,i length 39 feet, and width 25 feet; A greater length than 30 to 33 feet is not admissible since the scholars in the rear row of seats would be subjected to unnecessary eye-strain when looking at blackboards or other objects at the 1 op- posite end of the room. I Lighting. — The amount of glazed surface admitting - light to a school-room should be from one sixth to One- fourth as much as the floor space of the room, in ojrder to provide •sufficient light for all parts of the room in cloudy weather. This limit, however, may not be duffi- cienf in case of obstruction by trees, houses, or adjacent hillsi In crowded cities, and cither places where ^well- lighted locations are not available, the use of ribbed glass, and Luxfer prisms is ! reeorntnended for: the' pur- pose of increasing' the illumination. In the Building Rules of the Board of Education (England) .are the j fol- lowing excellent suggestions: " The light should, as far as possible, and especially in elassrroo'ms, be admitted from/the left side of the scholars. All other windows in class-rooms should be regardpn as supplementary, or for summer ventilation. Where left light is impossible, right light is next best. Windows facing the eyes of teachers or scholars are not approved. In rooms fourteen feet high any space beyond twenty - fourj feet from the window wall is insufficiently lighted. Windows should never be provided for the sake merely of external effect. All kinds of glazing which diminish the light and are troublesome to keep clean and in re- pair: should be avoided." ' Rooms having a northern exposure should, other things being equal, have a more liberal provision for light than those with a southern exposure. According to Shaw : 2 " If a school-room is insufficiently lighted and more light cannot be admitted from the left or near, the windows placed, on the right should have their sills, eight feet above the floor, and the amount of light admitted by such windows should in no instance be strong enough to overpower the light admitted from the left." Spaces between Windows. — The windows should be placed with as little space as possible between them, to avoid the production of alternate bands of light and shade which are injurious to the eye. Height of Windows. — The windows should extend as near to the ceiling as possible, since the higher they ex- tend the better the illumination. Windows arched at the top decrease the illumination. . Height of Window Sills. — The English rules advise a height of at least four feet above the floor. Some au- thorities advise a height of Ave feet, but this would in- terfere too much with the amount of glazed surface. Large single panes of glass for upper and lower sash allow the least obstruction of light, and readily admit of cleaning. Color of Walls. — No color should be used which absorbs light. Reds are to be avoided. Yellow is not restful to the eye. A pale greenish-gray, nearly white, appears to be the best suited for school-rooms. Window Shades. — Window shades are useful in bright sunny days, and especially when the grpund is covered with snow, to modify the effect of light. They should roll up from the bottom and should be somewhat darker than the walls. The direct rays of sunlight should not be allowed to fall upon any occupied desk. Arrangement of Seats.— The best arrangement is that which allows the pupils to face one of the shorter sides of the school-room, the windows being at the left of the scholars as they sit in their seats. It is also best to have the aisle at the side opposite the windows considerably wider than that upon the side next the windows. This allows some freedom of movement about the blackboards, as well as space for other school exercises (Fig. 4158). If the seats are arranged so that the scholars face the 69 School Hygiene. School Hygiene. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. long side of the room, those upon the outer rows are at some disadvantage in looking at objects on the wall be- hind the teacher, such as maps, etc. Blackboards. — The best blackboards are made of slate- stone, and should be either black or dark green. If blackboards are not used, slated paper, cloth, or walls □ □ □ □ □ a 1 □. □ □ an □ E3 □■ a □ n a □ □ .□ □ □ □ , □ □ □ □ □ □ □ □ □ □ □ □ i □ □ □ □ □ □ □ □ 1 ;° ° □ a n o o o □ o Fig. 4158. Scholars pany.) -^Model Arrangement of Seats; Windows at Left of (From Shaw's "School Hygiene," The Macmilian Com- may be prepared. For young scholars the bottom of the board should not be more than twenty -six inches from the floor, varying from that height to thirty -six inches for the okter grades. . Their width from top to bottom should be about four feet. Number of Stories.— When it is practicable, the number of stories should be limited to two above the ground. This rule is especially applicable to that class of schools in which the scholars frequently pass from one story to another during the day. Basement. — A basement should always be provided. Its walls and floor should be so constructed as to prevent access of dampness, and the walls should rise above the ground sufficiently to permit the entrance of sunlight. Hallways and Entrances should be sufficiently ample to allow the building to be rapidly emptied in cases of emergency. Stairways.— All stairways should be well lighted, and should be at least five feet wide, and should be broken by landings about half-way from top to bottom. Diag- onal steps, or spiral stairways should not be permitted. Steps with six-inch risers and eleven-inch treads are easiest for school children, but six and one-half inches may be allowed for stairs in high schools. Floors.— Floors should be made of well-seasoned hard wood, free from cracks. At the junction of the mop- board and the floor, a concave strip -will allow better cleaning and sweeping (Fig. 4159). The floors between the occupied stories should be made as nearly sound proof as possible. Cornices, mouldings, and other pro- jections which catch dust should be avoided. Moist sawdust may be used in the cleaning of floors. Bad floors should be replaced, or treated by planing, and filling the cracks. Pure oil is not so good an application for floors as preparations containing a considerable pro- portion of wax or paraffin, since the oil darkens the floor and interferes with the light. Cloak-rooms. — These should be provided, and furnished with shelves, and hooks for clothing, bats.and overshoes. TO They should be so arranged as to admit of free ventila- tion. Seating and Ventilation. — The importance of the proper heating and ventilation of school buildings de- pends largely upon the climate or region in which the school-house is located. In the tropics where windows may be open throughout the year, an abundant and con- stant supply of fresh air can be had, and the question of heating is of little consequence. In temperate climates, however, the subject assumes greater importance. The common modes of heating large school-houses are by hot air, steam and hot water. The two latter are generally preferable for large school-houses, since by them the rooms in different parts of a building can be warmed more equably than by hot air. In rural districts a supply of fresh air may be intro- duced by means of jacketed stoves after the manner described in the nineteenth report of the State Board of Health of Massachusetts, p. 315. s The ventilation should be of such efficiency as to provide a supply of thirty feet of fresh air for each pupil per minute. The inlets and outlets should be of such size that the incoming warm air shall not have a velocity of more than four hundred feet per minute, and this inlet, for a room of standard size, should not have an area of less than four square feet. A wire screen of one-eighth inch wire, with meshes of one and one-half inches, is better than a cast- iron register. The inlet and outlet should be on the inner or warm side of the room, the inlet being placed about eight feet above the floor, and the outlet in the floor or very near it. Temperature.— A. temperature of 65° to 68° F. should be maintained during school hours. Dr. Lincoln recom- mends 66° as a proper standard. Most English authori- ties are in favor of lower temperatures than these. Humidity. — Good ventilation requires a proper amount of moisture to supply the loss involved in heating the air to a sufficient degree to insure comfort. Various de- vices have been invented to supply this deficiency. The ordinary water-pots which are supplied with hot-air furnaces cannot be relied upon to produce a sufficient degree of humidity for health and comfort. Carbonic Acid as an index of impurity in the air. The amount of carbonic acid in fresh outdoor air is about 3 parts in 10,000.* In order to secure the highest degree of comfort and health for the scholar who spends a portion of his time every day in the school-room, the amount of carbonic acid in the air should not be allowed to ex- ceed 7 parts per 10,000. For the purpose of measuring the relative amount which may be present in an occupied school-room several devices have been invented, but none which have thus far been devised ap- pear to be capable of giving as satisfactory results as a quantitative analysis of the air by a competent chemist. Dr. Haldane has recently brought to notice a new apparatus for which he claims that "the analysis after some practice can be relied on to within 0.5 volume on either side of the right result." The apparatus, however, requires very care- \ 7 Fig. 4159.— Section of Concave Strip at Corners Between Mop Board and Floor. ful manipulation, since "a variation of 0.1° C. in the tem- perature of the water in which the air burettes are immersed would, unless compensated, cause an error of fully three volumes per 10,000 in the analysis. \ A sim- * Average of sixty-two analyses in summer and winter, in country air of Scotland. Dr. Haldane, in report of committee to inquire into the ventilation of factories and workshops. 1902. d 93 t Loc. cit., pp. 117 and 120. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. School Hygiene. School Hygiene. $le apparatus which can be used by the teacher in any school-room for the purpose of determining, at least ap- proximately and with facility, the relative amount of carbonic acid present in the, air of the room, under the Ordinary conditions of school attendance, is very much needed. Lavatories, Water- Closets, etc. — The best location for ffliese appliances, sometimes by an exclusive misapplica- Ifion of terms called " sanitaries, " is.in aseparate building outside the school-house. Inconsequence of the severity of the winters in northern climates, and the increased cost of heating, this is not always practicable, and these conveniences are usually placed in the basement in large buildings, especially where they are connected with, the public sewer system. No system, however, should be tolerated in which the ventilation of the water-closets is in 'any way connected with the general ventilation of the school. They should be well lighted. If latrines or troughs are used, they should be so constructed as to admit of thorough cleansing and flushing with water. Systems providing for the drying or cremation of ex- creta in the basement of school-buildings require the most careful janitorship, and are not to be generally recommended. Urinals.— These can be successfully maintained only in school-buildings connected with a public water sup- ply. Slate or asphalt is the best material for construc- tion. There should be an abundant flush of water, and a gutter at the bottom with a sufficient inclination to barry off the water rapidly to the drain or soil pipe. - The plumbing, the care, and management of the closets, latrines, and urinals should be of such good char- acter as not to require the use of disinfectants or deodor- izers. The substances often recommended to be placed in such places for the purpose of "disinfecting" the air do not disinfect, but merely substitute one smell for another. '. Outhouses in Country Districts. — In .districts not sup- plied with good systems of water and sewers, the main- tenance of convenient and cleanly outhouses is a difficult problem, since, without the strictest attention on the part of teachers and janitors, they are likely to become sources both of physical and moral uncleanliness. Such out- hbuses should be located at least forty feet from the school-house, and there should be entirely separate build- ings for each sex. These should also be separated by a tight board fence extending from the school-house, at least six and one-half feet in height. They should be ptovided with ample and well-cemented vaults, so con- structed as to admit of emptying and cleansing without difficulty. They should be so made as to exclude all water from any source, except that contained in the ex- creta. Provision should also be made for the storage of an ample supply of dry loam under cover. This can usu- ally be obtained during the warm season. It should be applied daily during the time of school attendance, a sufficient quantity being applied each day to cover the fresh contents of the vaults. Water /Supply. — In cities it is customary to provide a supply of water from the public supply. As a general rule such water is pure and wholesome. On the con- trary, instances have occurred in which the authorities have found it necessary to shut off the water of the pub- lic supply from the schools in consequence of serious pollution at the source. Lead pipe should not be used for the conveyance of water to the school-buildings nor for its distribution in them. It is desirable to have as many faucets on each floor as there are separate schools. There should also be opportunity for washing hands when coming from the closets and urinals, for which pur- pose soap and towels should be provided. In country schools the supply is often obtained from wells, and special attention should be paid to their proper loeatior in order to secure them from pollution. If there iiitay doubt as to, the quality of the water, it should be submitted to a competent chemist for analysis. School -j house wells should be thoroughly pumped out at the close of the vacations in localities where the water is not used through 1 the vacation. ' Water for the schools should not be kept in open pails, and the use of a separate drink- ing cup for each scholar should be encouraged. 1 l&llool Baths.— The provision of places for bathing in connection with the public schools, as introduced recently in a few cities, undoubtedly exerts a decided influence, moral as well as physical, upon the children of those schools, an effect which extends to the homes of such children, among a large portion of whom the facilities for bathing are of the most limited character. Added to this, in' schools which are provided with swimming tanks, the instruction given in this art has the advantage of being both healthful and of a life-saving kind. The swimming tank adds materially to the cost of mainte- nance, on account of the fuel required to keep a large body of water at a proper temperature. Shower baths are now provided in connection with several of the pub- lic schools in New York, Boston^ and other cities. In the town of Brookline, Mass., a public bathhouse erected in close proximity to the high school-house gives abun- dant opportunity to scholars in the public schools both for bathing and swimming all the year round. Scliool Furniture. — Since the scholar spends a large part of his school life seated upon some sort of seat, and, in all the higher grades, provided also with a desk, it is of the highest importance that these two articles of fur- niture should be as correctly made as possible. In an article by Dr. W. H. Burnham the following require- ments are given : i 1. The height of the seat should be about two-sevenths that of the body. , 2. The; width should be about one-fifth of thej length of the body, or three-fourths the length of the thigh. 3. Tjhe Seat should slope downward a little toward the, back, and be slightly concave, having bevelled edges in front. - i 4. A back rest is essential for hips and shoulders. 5. The correct " difference " or vertical distanpe from the seat to the edge of the desk is that which permits the child when sitting' erect to pla.ee both fprearms on the desk, without raising or lowering the shoulders. 6. Of equal importance is the "distance "* of the seat from the desk, which may be (a) "zero," (b) "positive," or (c) a " negative " distance, necessitating facility in ad- j ustmeht. ' 7. A desk slope, preferably of fifteen degrees for writ- ing, with capacity for adjustment to other purposes. 8. Strength, durability, and simplicity of construction. 9. Surfaces easy to clean, and unfavorable to the ac- cumulation of dust. 10. A. moderate price. The principal objections to badly contrived school seats and desks are the liability, to produce eye-strain and distortion of the spine. Almost any sort of seat may produce one or the other of these effects if pupils are kept continually sitting for long periods of time, without exercise, and especially if they are engaged in writing for lengthy periods. There is, however, a decided choice in school furniture, and the tendency is constantly in the direction of improvement (Figs. 4160 and 4161). According to Janke the edge of the desk should be of such height above the seat as to be opposite the navel of the scholar who sits erect, so that, in placing the forearm upon the table to write, the elbow must be bent a little to one side and to the front of , the scholar. 5 Much improvement has been accomplished in the United States by means of adjustable desks, so con- structed as to admit of change and adaptation to the wants of scholars at an age when growth is most rapid. Shaw says: "Desks and seats should' be adjusted ver- tically twice a year, at the opening of school in Septem- * Janke describes the "distance" as the horizontal Interval be-' tween a vertical line touching the front edge of the seat, and another , vertical line let fall from the edge of the desk. If these lines coincide, ; the "distance »' is zero ; if (he dqsk overlaps the seat, the " distance " is minus or negative ; if the edge of the seat falls to the rear of the edge of the Sesk, the "distance "is plus or positive. 71 > Scbool Hygiene. Schwalbach. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. ber, and again in February or March ; and at whatever time during the year a pupil enters school or is trans- ferred to another room, his seat should be adjusted to him." 8 Desks should be constructed to fit the children. According to Hope and Browne : " Short lessons at bad desks are likely to be less injurious than long eonfine- Frora Shaw's "School Hygiene." ment at the most perfect."' The sitting posture is in itself bad, and should be counteracted by active exercise. Hence the use of blackboards for drawing and writing by beginners in place of copy-books is earnestly advised. In most American schools at the present day fixed seats and desks are in use, but in Germany several authorities give preference to movable seats and desks, on account of the facility thus offered for cleansing the floors 6 (Figs. 4163 and 4163). As an instance of the serious effects produced by want of adaptation of school furniture to the ages and heights FIG. 4161. From Shaw's "School Hygiene." of children, Dr. C. F. Scudder reports that twenty per cent, of the girls in the grammar grades of the Boston schools were round-shouldered, as a result of malposi- tions due to defective desks and seats. 7 In several rooms he found girls who differed seven years in their ages, and nearly twenty-two and one-half inches in height, seated at desks and in seats of exactly the same size. In one school eighteen per cent, of tlie scholars, when sitting back in their seats, could not touch the floor with their heels. To counteract the ill effect of bad postures, even when properly adapted seats are supplied, periods of relief, to- 72 gether with exercises intended to correct bad habits of this sort should be given, to be repeated several times during each school day. During the first school year such periods should be more frequent than in the later years of school life. During the first year the child should not be confined at his desk more than one-third of the time. Notwithstanding all that has been said and written in recent years about the importance of physical culture in schools, the tendency is still to train the mental faculties Fig. 416-. — Double Seat, used in German Schools. Movable and dur- able, but clumsy. at the expense of the physical development of the scholar. There is consequently a decided necessity for devoting a greater share of each day's work to physical exercise. The recess should be maintained, and at least fifteen minutes in each session should be given "in which all scholars should, so long as the weather and climate permit, go out of doors, and engage in some form of physical activity" (Shaw). And this period of relaxa- tion should be in addition to the regular S3*stematic exer- cises which should form a part of the programme of each school day. The Medical Inspection of Schools. — in most European countries at the present day, the sanitary au- German Double Seat. Movable. thorities exercise some sort of supervision over the public schools. 8 The well-known work of Dr. .Taussens at Brussels has for years served as a model in this direction. In PYance, as early as 1842, it was ordered that every REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. School Hygiene. Schwalbach. public school should be visited by a physician, who should inspect the localities and the general health of school children. New regulations defining explicit duties of such medical inspectors in Paris were adopted, and went into effect January 1st, 1884.* The first systematic medical inspection of schools in America was inaugurated in the Boston schools in 1894 on the advice of Dr. S. H. Durgin, chairman of the Bos- ton Board of Health. Since that time New York, Phila- delphia, Chicago, Hartford, Milwaukee, and other cities have adopted a similar course. The principal object at first aimed at was the search for unrecognized cases of infectious diseases, by which means it was believed that much could be done toward preventing their spread. Much good, however, can be accomplished in other di- rections toward improving all those conditions, both sub- jective and objective, which relate to the health of school children. In Boston the city is divided into fifty districts, each of which is provided with an inspector who visits each of the schools in his district daily in the morning. Chil- dren who appear to be ill from any cause, and especially those suffering with incipient infectious diseases, are sent to their homes. The teachers soon become familiar with the work and render efficient aid to the inspectors. The principal diseases detected by such inspectors, as shown by the experience of inspectors in different Amer- ican cities, are the specific infectious diseases of child- hood, whooping-cough, measles, mumps, chickenpox, diphtheria, scarlet fever, influenza, and tuberculosis, also laryngitis and tonsillitis, rhinitis, acute bronchitis, sup- purative diseases of the ear, acute catarrhal conjunctivi- tis, imperfect sight, and contagious skin diseases, espe- cially pediculosis, which often proves a serious pest among school children. Eyesight. — Every possible means should be used to pre- vent impairment of the eyesight of school children, since the demands of school life impair the eyesight of a very large percentage of those who pass through the curricu- lum of several years. The types employed in printing school books should produce letters of the most legible character, and the lines should be amply spaced or leaded. Cohn advises that the length of the lines should not be more than 10 cm. (4 inches). White paper with a dull, unreflecting surface is best for the eyes of school children. Blackboards should be kept clean and black, and should not be allowed to become gray in consequence of reten- tion of particles of chalk. As a general rule, slates are not so good as paper. They become greasy, and the writing is generally more illegible than when it is written upon paper. Other sanitary reasons are also urged in forbidding their use. Children should not be permitted to assume bad post- ures while writing, since they also injure the eyesight. The pupil should sit erect, and the book should not come nearer to the eyes than twelve inches. Testing the Eyesight and Hearing. — Every teacher should know how to make the common tests for eyesight and hearing, which should be applied soon after the be- ginning of the school year, so that children who are found to be short-sighted or defective in hearing may be prop- erly seated near the front of the room. In schools where medical inspection is regularly made, this examination should be conducted by the medical in- spector. Children are often punished or regarded as dull , when there is either a defect of the vision or of the hear- ing. Defects of the eyesight should be reported to the parents, so that a thorough examination may be made by an oculist and the proper glasses furnished. Samuel W. Abbott. Bibliographical Rkferences. 1 Hope and Browne : Manual of School Hygiene, 1901. a Shaw, E. E. : School Hygiene, New York, 1901. * Palmberg's " Public Health and Its Applications." 8 Pinkham, J. G.: The Ventilation of School Rooms heated by Stoves. Nineteenth report of State Board of Health of Massachusetts. 1 Burnham, W. H. : Outlines of School Hygiene, in Pedagogical Seminary, vol. ii., No. 1, 1892. 6 Janke : Grundriss der Schulhygiene, 1901. "Eulenberg: Schulhygiene. 7 Scudder, C. F. : Seating of School Children and Lateral Curvature of Spine. School Document No. 9, Boston, 1892. 8 United States Commissioner of Education, Medical Inspection of Schools, Report, 1897-98, vol. ii. Bernstein : Vierterjahrsschrlf 1 1 . gericht. Med. u. Gesundneitswesen, 3, 1902. Bowditch, H. P. : The Growth of Children. Billings, J. S. : Ventilation and Heating, New York, 1893. Burgerstein : Notizeu zur Hygiene des Unterrichts und des Lehrer- berufes, Jena, 1901. Burgerstein and Netolitzky : Handbuch der Schulhygiene, 1900. Ctiapin, C. V. : Municipal Sanitation, Providence, R. I., 1901, p. 7. Cohn, Hermann : Lehrbuch der Hygiene des Auges, 1892. Eighth and Twenty-second Annual Reports of State Board of Health of Massachusetts, 1877 and 1890. Hartwell, E. M. : Reports of Director of Physical Training, Boston, 1894 and 1895. Lincoln, D. P. : Report of Committee on School Hygiene. Amer. Med. Association, Chicago, 1893; also article in Buck's Hygiene and Public Health, vol. ii.. New York, 1879. Marble, A. P. : Sanitary Condition of School-Houses. Bureau of Edu- cation, Washington, D. C. Pettenkofer : Ueber Luf t in den Schulen, 1862. Ravenhill, Alice: The Teaching of Hygiene in the Schools and Col- leges of the United States. Journ. San. Institute, April, 1902, p. 27. Risby, S. D. : School Hygiene and Diseases of the Eye, Philadelphia, 1897. Winsor, F. : School Hygiene. Fifth Report of Massachusetts State Board of Health, 1874. Young, A. G. : Seventh Annual Report of State Board of Health of Maine, 1892. SCHWALBACH is a spa situated in the province of Hesse-Nassau, Prussia. It lies in the valley of the Miln- zenbach, about twelve miles from Wiesbaden, and five miles from the health resort Schlangenbad. Its eleva- tion is 972 feet above sea level, and as it is well protected against all but the southerly winds, its climate is mild and well suited for invalids. There are eight mineral springs at Schwalbach, known as the Wein-, Stahl-, Rosen-, Paulinen-, Ehe-, Neu-, Linden-, and Adelhaid- Brunnen. There is but little difference in the composi- tion of the waters of these springs. The following is the analysis of two of the springs, as made by Fresenius. In 1,000 parts there are, of: Wein r Brunnen. Linden-Brunnen. 0.037801 .009085 .245345 .572L29 .605UM 0009902 .004680 .042317 429277 .395267 .002205 .002033 .668630 .006193 .007469 001048 .017622 .016156 006414' .005541 Trace. .000438 .000197 .046500 .000046 .032821 .000003 1.558318 0.965921 The gases are carbonic acid and a very small propor- tion of sulphureted hydrogen. Schwalbach is a favorite health resort, and is visited by several thousand guests every year. The diseases for the relief of which a course of treatment at this spa is recommended are anaemia and chlorosis, epilepsy, chorea, progressive muscular atroph}', neuralgia, neurasthenia, hysteria, and other functional and organic nervous dis- orders, Bright's disease, diabetes mellitus, chronic vesi- cal catarrh, and various affections of the female sexual organs. The waters are employed externally and internally, according to the individual indications, and facilities are afforded for pine-needle, mud, vapor, and other baths. The season lasts from May to October. There are excel- lent accommodations for visitors. T3 Sciatica. Scl erode r m a . REFEIIENCE HANDBOOK OF THE MEDICAL 1 SCIENCES. SCIATICA. See Neuralgia. SCIRRHUS. See Carcinoma. SCLERA. See Eye. SCLERA, DISEASES OF THE.— Although the sclera becomes secondarily involved in various morbid proc- esses originating in other parts of the eyeball, primary disease of this structure is comparatively rare. Scleritis, or inflammation of the sclerotic, as a primary affection, is recognized onty as originating in a narrow zone of the sclera, bounded in front by the cornea and behind by the insertion of the recti muscles. In this situation we meet with two varieties of scleritis — simple and complicated. Simple Scleritis (episcleritis) commences as a local- ized subconjunctival hyperemia at a short distance from the corneal margin. As the episcleral tissue becomes in- filtrated, a smooth swelling appears, which is but slightly elevated above the surrounding surface, and is usually of a dingy yellowish-red color, sometimes resembling a pustular formation, though ulceration or loss of sub- stance never occurs. The conjunctival vessels over and around the swollen part are more or less engorged, but the conjunctiva in general remains normal. After a few days or weeks the nodule assumes a dull violet hue and becomes flatter, in which form' it may remain stationary for a long time, or may gradually disappear, leaving a more or less permanent dull gray or ash-colored spot. Occasionally two or more such nodules! are present at the same time, or as one disappears others may develop. The slow progress and tendency to recurrence of these nodules frequently render the disease tedious and pro- tracted. One or both eyes may be affected, or as one re- covers the other may undergo the same process. I The subjective symptoms are seldom severe; they con- sist in an unpleasant sensation of weight or pressure in the eye, undue sensitiveness to light or cold, and perhaps sight headache; rarely there may be considerable photo- phobia and sharp pain. This disease belongs almost exclusively to adult life, and is most: common in elderly people. The gouty, the rheumatic, and the scrofulous diatheses are all credited with lending a predisposition to this form of scleritis. f Treatment. — Any special dyscrasia on the part of the patient must be taken into account and suitably dealt with ; and while exercise in the open air is to be enjoined, the eye must be protected from strong light and from sudden changes of temperature. The local use of sul- phate of atropine is allowable in the early stages, espe- cially if there be marked symptoms of irritation. In the absence of these, instillations of solution of eserine — gr. i or 1 to the ounce— twice daily, are often very efficacious. Massage, with the employment of oxide of mercury oint- ment (amorphous yellow oxide of mercury 1 part, and fat or vaseline 25-50 parts), has been highly recommended. Dry or moist heat, applied to the eye in the usual way, several times daily, may be beneficial. In regard to internal medication, the choice of remedies will depend on various circumstances. Mineral waters, iodide of potassium, salicylate of soda, protoiodide of mercury, hypodermic injections of pilocarpine, and many other remedies have been used with more or less success, according to the special indications present in the indi- vidual case. Complicated Sclebitis (sclero-keratitis, scrofulous scleratitis). — This is a much more serious affection, owing to the involvement of the Cornea, iris, and ciliary region in the inflammatory process, and also to the tendency which exists to disastrous changes in any or all of these parts. Sclero-keratitis, commencing in the sclerotic, begins with one or more dusky infiltrations of the scle- rotic, as in simple scleritis, but close to the corneal margin, the cornea being involved from the first, or after the scleral affection has existed only a short time ; the peri- corneal tissues are more deeply and more generally in- volved than in simple scleritis, and in some cases the cornea becomes extensively opaque ; sooner or later the u iris may participate 7 in 'the inflammation, as is shown by visible changes in its appearance and by the presence of posterior synechia, or the entire ciliary r region may be- come intensely congested and sensitive (iridocyclitis). The special dangers to whichi the eye is subjected in any given case maybe approximately estimated by the sever- ity of the disease in the several parts affected— extensive Changes in the cornea threatening permanent opacity of this structure; in the iris, more or less com pfete posterior synechia, and in the ciliary region, ciliary staphyloma. There may be one or more foci of inflammation; when there are several of these, the entire pericorneal zone may be involved, or the same thing may happen more slowly through repeated relapses, each time a different area of this zone being attacked. The low dusky swell- ing of the sclerotic, continuous with a patchy opacity of the adjacent cornea, is the characteristic objective sign Qf this disease, which, as a rule, is subacute in all its manifestations. Occasionally, however, the inflamma- tory process is more active, and there are intense photo- phobia, considerable lachry mation, and severe pain. The disease may at any time subside, leaving a dull grayish, thickened appearance of the sclerotic, and a correspond- ing irregular marginal opacity of the cornea. If several foci have been present, the cornea will have the appear- ance of being irregularly encroached upon by the scle- rotic. With the subsidence of the inflammatory process the dull slaty-gray sclerotic may present a zone of thick; ened tissue around the cornea, which sometimes looks as if it, were pushed forward, giving the anterior part of the eyeball an elongated appearance ; or, more frequently, the sclerotic immediately around the cornea yields in cer- tain places, and an irregular, nodular-looking projec- tion (intercalar staphyloma) is formed behind the cornea. This prominence is sharply defined anteriorly, but be- comes gradually flattened toward the level of the normal sclerotic posteriorly. After repeated attacks of inflam- mation the staphylomatous bulging may involve the en- tire circumcorneal zone of the sclerotic, giving rise to great enlargement and distortion of the anterior part of the eyeball; at the same time the iri3 may become ex- panded from the periphery, and the anterior chamber is often considerably enlarged. The development of sta- phyloma in this class of cases does not often depend on increased intraocular tension, but on a gradual expansion of the softened sclerotic. If the staphyloma is to be re- garded as evidence of increased tension we must assume that the softened sclera has yielded more readily than the nerve entrance ; otherwise it would be difficult to under- stand the well-known fact that extensive changes in the form and appearance of the eyeball are under these cir- cumstances not inconsistent with fairly good vision. The subjects of this disease are usually young adults, and it affects women far more frequently than men. " It is not known to be associated with any special dyscrasia, but generally occurs in persons with a feeble circulation and a liability to ' catch cold ' ; in some cases there is a definite family history of scrofula or phthisis " (Nettle- ship). Treatment— During the irritative stages soothing rem- edies are indicated. Protection from cold air and strong light is always advisable, warm fomentations are gener- ally beneficial, and instillations of atropine are useful if there is much irritation, especially if the iris is at all in^ volved. In the more acute forms of this disease the writer has seen great improvement follow the use of antipyrin in doses of fifteen grains several times daily. Mercury may be used in moderation if the patient is not too ansemic. If a distinctly rheumatic or gouty tendency exists, the usual constitutional treatment for these conditions is in : dicated ; in some cases colchicine is very useful, in others diaphoretics, such as pilocarpine hypodermically, give excellent results. Iridectomy may be performed if there are extensive adhesions of the iris and a tendency to the development of staphyloma. If vision is destroyed and the eyeball is greatly enlarged, an operation for the re- moval of the staphyloma may be indicated/ REFERENCE 1 HANDBOOK l OF' "THE 5 MEDICAL' SCIENCES. Sciatica. Scleroderma. '' ! Staphyloma of the Sclera (ectasia) occurs under the most varied Conditions, but usually as the result of prolonged increase of intraocular tension. As a congenital anomaly of rare occurrence there is sometimes a partial bulging of the sclerotic, associated with congenital coloboma of the choroid (seleral protu- berance 6f von Ammon). 11 Extensive destruction of the cornea from suppurative keratitis is commonly followed by more or less complete corneal staphyloma, and this may extend to the sclera, giving rise to more or less general enlargement of the eyeball. ' Iridocyclitis and iridbchoroiditis; followed by occlusion of the pupil, give rise to increased tension of the eyeball, and this in the course of time, if not relieved, causes scleral staphyloma, usually in the ciliary region. Protracted increased tension from neglected glaucoma (glaucoma consummatum), or from dislocation of the lens, is a common cause of scleral staphyloma. Under these circumstances the bulging is usually far back, behind or between the insertions of the recti muscles. In an ectasia following inflammatory or glaucomatous processes the protruding part is lined by a correspond- ing portion of the stretched and attenuated uveal tract. Bulging of the sclerotic may occur at any part, during the course of suppurative panophthalmitis, prior to rupt- ure of this tunic and the escape of the contained pus. Intraocular growths likewise cause bulging of the sclerotic, either by softening of the tunic in the vicinity of an intraocular growth, by the increased tension which such growths induce, or by simple expansion from ex- cessive development of the growth. For the diagnosis of these conditions, see article Bye, Tumors of. Ectasia of the sclerotic at the posterior pole (sclero- ectasia posterior), as met with in axial myopia, is a condi- tion of frequent occurrence. (See Myopia.) Its presence is easily determined, by means of the ophthalmoscope, by the existence of a crescent or irregular circle of cho- roidal atrophy, which nearly always commences at the temporal side of the optic papilla. Frank Buller. SCLEREMA NEONATORUM.— This rare disease of early infancy, to which a number of other names have been given at various times, such as algidite progressive, induratio tela cellulosm, Vendurcissement athrepsique, was first described by Underwood as a hidebound condition of the skin occurring in new-born infants. At birth, or shortly after, a peculiar induration of the skin appears, usually first upon the lower extremities, whence it spreads rapidly to other parts of the integument, involv- ing the entire surface of the body in a few days. When the disease is fully developed the infant appears as if frozen ; the surface of the body is cold ; the skin is hard and wax-like at first, but later usually becomes some- what livid; the limbs are fixed and rigid, and, owing to the stiffness of the cheeks and lips, suckling is impossi- ble. The respirations are weak and shallow, and the cir- culation is feeble. Death commonly occurs within eight or ten days. The disease may be congenital, in which case the infant is either stillborn or dies within a day or two. The affection is most probably due to malnutrition arising from improper or insufficient food, poor hygienic surroundings, or previous exhausting disease. It may follow cardiac disease, gastro-intestinal affections, disease of the lungs, or any other malady which greatly lowers the vitality of the infant. The congenital cases or those which occur a day or two after birth are of unknown origin. According to Langer, the induration of the skin arises from solidification of the fat, brought about by the abnor- mally low bodily temperature, the fat of infants, owing to differences in composition, solidifying at a much higher temperature than that of adults. This explanation, how- ever, is not entirely adequate. Parrot, who first distin- guished the affection from oedema neonatorum, with which it was for a long time confounded, believes it to be a drying out of the tissues brought about by the draining off of the fluids of the body by previous debili- tating disease. This author finds the skin thinner than normal, the 'fat diririnished, and the vessels, especially of the papillary layer, greatly contracted. Ballantyne agrees in the main with Parrot's conclusions. The only affections with which sclerema neonatorum is likely to be . confounded are scleroderma and oedema neonatorum. From the former it may be distinguished by the early age at which it occurs, no case of sclero- derma having yet been observed in the first few months of life. From oedema it differs in the waxy appearance 6f the skin, the absence of pitting on pressure, the rigid-" ity of the limbs, and the more general distribution of the cutaneous changes, oedema being most marked in the de- pendent parts of the body. The prognosis is extremely unfavorable, death occur- ring in almost all cases. In the exceptional cases in which thp entire surface is not involved, recovery may take place. Treatment consists in the employment of measures to increase the temperature of the body, which is always much below, the normal, and the administration of easily digested food and stimulants. As the infant is unable to nurse, it is necessary t6 administer the nourishment with a flexible tube through the nose, or by enema. Milton B. Hartzell. SCLERODERMA. — Scleroderma {aK\r/po(, hard; iep/ia, skin) — also known as sclerodermia, sclerema, scleroma adul- torum, scleria&is—is a rare, chronic disease, characterized by a peculiar hard, leajthef-like condition of the skin occurring in diffuse areas or in sharply circumscribed patches. The circumscribed form, sometimes called morplum and regarded by some authors as a distinct af- fection, has been fully described elsewhere and will not be considered here. Diffuse scleroderma begins either acutely or insidiously with slight stiffness of the skin, which usually presents a certain amount of swelling and hardness. Vague pains in the 'joints and muscles may precede the alterations in the skin, but marked or char- acteristic prodromal symptoms are usually wanting. The induration and stiffness of the skin spread slowly or rapidly (more commonly the former) over considerable areas, and in rare cases the entire integument becomes in- volved. When the disease is fully developed the skin is remark- ably firm and inelastic, smooth or slightly scaly, no longer susceptible of being picked up between the fingers, and more or less adherent to the underlying tissues. While the color of the skin is Usually white or yellowish-white, a considerable amount of pigmentation is often present in the shape of streaks and macules of various shades of • brown. Subjective symptoms are, as a rule, slight. There are a feeling of tension and occasionally more or less itching. Tactile sensibility is as a rule unaltered, but in excep- tional cases there may be slight hyperesthesia or anaes- thesia. The functional .activity of the glands of the skin in mild cases is usually unaltered, but in advanced or severe ones the excretion of sweat and sebum is diminished to a greater or less degree. When the skin about the joints is affected movement is more or less interfered with, and in atrophic cases ankylosis with consequent complete immobility may re- sult. When the face is attacked, the features are motion- less, as if covered with a mask ; the nose is pinched ; the mouth contracted so that it is opened with difficulty; the eyes are only half-open or staring, owing to the im- mobility of the lids. If the skin of the thorax is involved extensively, the movements of respiration may be con- siderably impeded. The parts most commonly affected are the face, the neck, the upper portion of the trunk, and the upper ex- tremities, but no part of the integument is exempt, al- though the palms and soles are rarely affected. In some cases the morbid process is not confined to the skin, but attacks the mucous membranes of the mouth, pharynx, larynx, and vagina. 75 Scoliosis. Scropliulariacete. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. In the great majority of cases constitutional symptoms are absent, but in those exceptional ones in which the affection begins acutely with marked oedema of the skin, spreading rapidly over a considerable surface, constitu- tional disturbance, such as chills and fever, may precede or accompany the alterations in the skin. . The course of the disease varies within considerable limits. When it has reached its acme, it may remain unchanged for months or years, and then the induration may slowly disappear, the skin resuming its normal sup- pleness and softness; or, after the disease has progressed toward recovery for a time, relapses may occur and new areas be invaded. On the other hand, the skin may become more tense, thinner, and parchment-like; the subcutane- ous cellular tissues and fat may disappear, and the un- derlying muscles atrophy. When this atrophic process affects the extremities they are greatly reduced in size, distorted, and the joints ankylosed. When the hands are affected great distortion of the fingers with marked wasting occurs, a condition which has been described as sclerodactylia. Owing to the extreme tension of the skin ulceration readily occurs, especially over bony prominences. The general health is, as a rule, but little if at all affected ; but in very extensive cases with atrophy, especially if accompanied by ulceration, death may take place from exhaustion. But little is known concerning the immediate causes of scleroderma. It occurs much more frequently in the female sex than in the male. In the cases collected by Lewin and Heller (four hundred and thirty -five in num- ber), two hundred and ninety-two, or sixty -seven per cent., were women. Age seems to have but little influ- ence upon the frequency with which the malady occurs, although it is most frequent between twenty and forty years of age. Exposure to cold and damp appears to exert a predisposing influence. In a certain proportion of cases the affection has followed some disease of the nervous system, and in a number of instances (sufficiently numerous to indicate more than an accidental association) traumatism of some kind has immediately preceded it. In many cases, however, if not in most, the patient has been in good general health at the time of the beginning of the morbid changes in the skin. Although the pathology of scleroderma is quite ob- scure, there is much in favor of the view that it is pri- marily an affection of the nervous system, a trophoneu- rosis; this, however, yet remains to be demonstrated. According to Crocker the various symptoms are produced by obstruction to the arterial and venous blood supply, and by interference with the flow of lymph, these being responsible for the alteration in the nutrition of the skin which characterizes the malady. Unna finds the chief pathological alterations in an hypertrophy of the collag- enous tissues affecting all parts of the cutis, and conse- quent atrophy of the blood-vessels and the epidermis. The changes in the epidermis are slight, consisting of occasional deposits of pigment and mechanical altera- tions due to pressure. A considerable exudation of small round cells surrounds the narrowed blood-vessels, the sweat and sebaceous glands, and the hair follicles. The lymph spaces are narrowed, and, in the cases in which atrophy occurs, an obliterating endarteritis is present. The symptoms of a typical, well-developed case of scleroderma are usually so characteristic that the diag- nosis is readily made. The peculiar induration of the skin characteristic of the malady is found in no other disease except sclerema neonatorum ; but this latter affection is met with only in the new-born and the in- duration of the skin is accompanied by marked cold- ness of the surface. The prognosis is decidedly unfavorable. While it is true that a certain small proportion of cases end in recov- ery, the disease usually lasts for years even when recov- ery does take place. When atrophy occurs, a return of the skin to its normal condition is not to be expected. In cases in which a considerable part of the integument 76 is involved, interfering greatly with movements of the limbs, death may eventually take place with symptoms of marasmus; or, owing to his debilitated condition, the patient may fall an easy prey to some intercurrent af- fection. Treatment.— Patients with scleroderma should be given an abundance of easily digested, assimilable food, such as milk, eggs, and butter. The clothing should be warm and abundant, so that there may be no danger of chill. Such tonic remedies as iron, quinine, arsenic, cod-liver oil, may be given with the view of improving the patient's general health. Massage and frictions with bland oils and fats should be systematically and persistently employed for the purpose of improving the nutrition of the skin. Mild galvanic currents may be applied to the indurated skin to improve the circulation and nutrition.. Drugs have little, if any, direct influence over the course of the disease. Thyroid extract has been given with asserted good effect, but its value is doubtful. Hans Hebra has reported marked benefit from hypodermatic injections of thiosinamin, one-half a Pravaz syringeful of a fifteen- per-cent. alcoholic solution being given every second day; and more recently Neisser has recommended the same treatment. Liebreich found considerable improvement follow the internal use of cantharidin in doses of 0.0002 gm. Milton B. Harttell. SCOLIOSIS. See Lateral Curvature of the Spine. SCOPOLA. — (Scopola Belladonna; incorrectly, "Jap- anese belladonna. ") The dried rhizome of 8copola carnio- lica Jacq. (fam. Solanacea). This drug is chiefly of interest at the present time because of the very extensive use of its extract, like that of belladonna root extract, to substitute belladonna leaf extract, which last is officially directed to be used in the manufacture of belladonna plaster (see Belladonna). Scopolais, however, likely to be introduced into the forth- coming edition of the Pharmacopoeia. The very similar species Hedge Hyssop is the common name of a little perennial herb, Qratiola officinalis L., of Europe,; -which contains one or more gluposides, the very bitter crystalline one, gratiolin, being apparently the active agent. Its meclic- ,inal properties entitle it to a thorough investigation, since it is so active as, to constitute a rather powerful emetico-cathartic poison, with marked diuretic properties. Its use, in doses of 0.2-1 gm. (gr. iij.-xv.), has been ; wholly unscientific, applying especially to gout and rheu- matism. ! • Figwort is the dried herb of one or, more species _of Scrophularia, the genus from which the family takes its name. Like the last, the drug has not received any scientific investigatiqn. Its bitter crystalline contituent, probably a glucoside, has been called scrophularin. There is also a very small amount of a volatile oil. Figwort appears to have some slight anthelmintic powers, but has been chiefly used, like mullein, in the form of a poultice. Its use is far more common in Europe than in this country. Henry H. Busby. - SQURVY ; SCORBUTUS.— (Including Barlow's Dis- ease.)— Definition. — Scurvy is a systemic disease. de- pendent upon an improper or ill-balanced dietary, char- acterized in its general expression by anaemia (secondary),, hemorrhages into the skin and subjacent tissues; spongy or ulcerating gums, progressive debility and emaciation, resulting in death unless checked in. its course by the necessary dietetic and medicinal treatment. The word scurvy is probably of Scandinavian origin, the Swedish skorbjugg, Danish skojeerbug, being equivalent to the Ger- man Scharbock, meaning soft or related stomach. General Considerations. ^-Throughout all ages scurvy has been one pf the classical diseases of mankind, and although it has been successfully eliminated as one of the social and sanitary problems of civilized: life, yet it would be a great mistake to infer that, by reason qf our better knowledge oi its causation and character, it has ceased to be a possibility in our modern surround- ings. Cases continue to be reported in our most recent journals. ;Theancien;t writers abound in references to it, giving in fanciful terms their theqries as to, its nature and cause. In his, work on " Airs, Abaters, find Places^" Hippocrates describes the disease in an unmistakable manner, , and Pliny and Strabo;, give, us, satisfactory ac- counts of scurvy as it appeared among the. troops in the campaigns of beesarfGermanicus and iEliu? Gallus, In- deed, it has been from time immemorial the scourge of armies, ravaging the ranks of the crusaders, the soldierjs of the Middle Ages in their long sieges, the cohorts of Napoleon in Egypt, and even the troopers of the last decade of the nineteenth century, in all parts of the world wh,ere warfare is carried on under climatic or dietetic conditions new and strange: to the soldier. In our own country it has invalided half ;a garrison, at Council Bluffs (1820) resulting in a mortality of over thirty per cent., and later during the Mexican war our troops suffered from its appearance while in that coun- try. During the civil war the statistics of this disease show a total of 46,910 cases jn the Union army, of which 771 proved directly fatal, a small relative ratio, but it undoubtedly expended its force indirectly as a con- tributary factor in the termination of other cases with which it was concurrent. The same experience is re- corded in the Crimean War, where 23,365 cases occurred in the French army, and 17,557 in the British army, while the numbers in the Turkish army were almost countless, as that force was practically decimated by its ravages. The Franco-Prussian war again recorded its appearance, though with a much lessened ratio of invalidism, and the Russo-Turkish "War repeated the story. In the German army, as late as 1897, there were seventy-four cases of scurvy, and in the Russian and Austrian armies, the same year, a ,ratio of over one per thousand; strength;. But in the popular conception, as well as in the profes- sional mind, scurvy is looked .upon as a disease of the sea, and of thqse "who, go down to the sea in ships and have their business in great waters." Beginning with the first known geographicalexplorations of the fifteenth century, involving long, .voyages in unknown oceans,, the records of those famous discoverers always included with their marvellous talqs of " new-found lands " the story of sufferings and death among their intrepid sea,- men from the disease; then known as scurvy. Pierre Quirino, Vasco de Gama, and Jacques Carrier all record the ravages of this disease among the crews of theix vessels.. As late as the eighteenth century Anson lost more than four-fifths of his men while, sailing round the world. Coming down to modern times, the experience of the: Marine-Hospital Service of the United States,, whose function is, in part, to care for sick and disabled seamen of the merchant marine, is the most accurate index to its prevalence among American sailors, as well as a few of other flags who are treated in our marine hos- pitals. From the statistics compiled for a period of twenty-eight years (1872 to 1899 inclusive) the following table has been constructed to show its occurrence and fre- quency : Cases of Scurvy Treated in United States Marine Hospitals from 1872 to 1898 inclusive. Year. Number of cases scurvy. All diseases treated. Year. Number ' of cases scurvy. All 'I diseases treated.' 1872 18 47 59 25 SB 13,156 13,529 14,356 15,009 31,983 39,155 24,860 32,613 36,184 40,195 44,761 41,714 43,822 45,314 1888 17 32 28 32 30 34 27 14 24 20 6 3 48,203 1873.. 1889 49,518 50,671 1874 1890 1875 . : .. 1891 52,992 1876^77 .. 1892 53,610 53,317 1877 79 . . i . 24 1893 1880.'..'...,. !l881... ..... 39 42 55 43 ' 27 34 18 ■ 37 1894 52,80£( 1895 52,643 1882 1896 53,804 54,477 52,709 1883 1897 1884 1898 1885. 1899 55,489 1886'..,: 1887. ,. ; 824 1,066,887 This is less, than one per thousand cases treated for the period stated. Dividing the twenty-eight years into three periods, the following result is obtained : 1872-1880, 3,01 cases; 1881-1889, 305 cases; 1890-1899, 218 cases. These figures require but little explanation beyond stat- ing that about half of the cases of scurvy treated by the .service is reported from the stations on the Pacific coast, principally San Francisco. These cases are taken from vessels coming "round the Horn " from England or else- where, a long voyage of several months, in which the conditions of diet, confinement, lack of exercise, etc., aid the development of the disease. While on duty at San Francisco the writer had opportunities to study and treat about seventy -five cases of scurvy in the course of three years, and it is from this experience that he has derived his practical knowledge of the disease. Etiology. — Scurvy — speaking in general terms — is a disease dependent on diet and occupation. It exists either ;in epidemic or in endemic form whenever persons subsist for a prolonged period on a dietary which does not con- tain fresh vegetables, or vegetables in a properly pre- served state. This condition, when aggravated by an unsanitary environment, is thereby accentuated. It is still a subject of controversy what may be the precise elements in this vegetarian problem, to the lack of which are logically due the scorbutic symptoms. Everything, however, tends to the conclusion that the disease is de- pendent upon the insufficient ingestion or the deprivation of the_ potassium salts of fruits and vegetables. These salts, in which potatoes, for example, are so rich, must have a very potent influence in maintaining the alkalinity of the blood and preventing acid intoxication. When to this lack of vegetables, with their organic and inorganic 78 REFERENCE- HANDBOOK OF > THE MEDICAL SCIENCES. Scurvy. Scurvy. elements, is added the enforced adhesion to a meat diet ( especially if salted/or preserved by; other similar proc- esses, we have the ideal' conditions under which scurvy begins and maintains its invasion. Resulting from this is a probable hyperacidity of the blood through the loss of the carbonates derived from the vegetable salts and the following loss of coagulability, with progressive an&mia. In this state of theoretical acid intoxication there is an increase in the ammonia-neutralized acid excreted as compared with the free acid. The blood is found to be dark and thin. The morphological changes are those of secondary ansemias, as from hemorrhage. Various observers have noted the changes in the count of red cells in proportion to the severity of the disease-, the duration, . and the hemorrhages. Megaloeytes and shrunken microcytes have been seen in grave cases. , Red cells in solution in the plasma are reported by Albertoni. The Hb index is low, according to White,' while several other 1 investigators have made conflicting statements as to the relative ratios of iron, sodium, and potassium salts and leucocytes. Altogether, the present state of knowl- edge of the morphology of the blood is not enlightening, and further studies are necessary to determine the signifi- cance of the conditions which are claimed by them as pathognomonic. A recent contribution to the discussion on this portion of the subject is that made by Albertoni, who has shown in some studies of the chemistry of the blood and of digestion that there is a serious deviation from normal in the freeHCl of the gastric juice, that intestinal putrefac- tion is excessive and that the urine furnishes abundant evidence of the absorption of toxins, while thel absorption of fats and carbohydrates is deficient. He concluded that the greenish-yellow color of the serum and the ex- cess > of pigments in the urine were proofs of active -destruction of the blood cells. As a corollary to this toxic indication may be men- tioned the theory, worthy of investigation, that the dis- ease is in reality a chronic' ptomai'n pdisoning due to putrefactive changes in badly preserved animal food, such as salt beef and canned meats. It is held that if these provisions were properly sterilized there would be no 'scurvy. It is not an 1 infrequent complaint, among seamen suffering from scorbutic conditions that the " salt horse "was of an' Offensive odor, and this observation was made among the laborers employed on the' construc- tion of a transcontinental railroad where scurvy appeared among foreigners who used this tainted meat with a plentiful supply of flour, beans, and peas. ' Scurvy is not believed to be contagious or infectious. Thus far no micro-organism has been found! to be of de- termining value in such investigations ashavebeen made by investigators. The field has not proved to be an in- viting or fertile one for bacteriologists of admitted skill. Some experiments have been made with the blood of scorbutic patients, with portions of the spongy gums and with material taken from the hemorrhagic lesions, but the results are not satisfying nor constant. It has been noted in epidemics that children suckling scorbutic mothers did not develop the disease, and in a given ship from which 'cases of scurvy have been taken, except in extreme conditions, only the forecastle, where the diet was restricted to certain kinds of food, would be invaded. Isolated cases of scurvy have been found dependent upon conditions that favor either the nutritional, the toxic, or the infectious theories of the etiology of the disease ad- vanced by various writers, but thus far the deficient vegetable dietary offers us the most practical evidence in our search for a factor that responds to. all the tests of probability. Ever since Bachstrom set forth this theory in 1734— viz., the lack of fresh vegetables in the food— it has held its' ground through the successive investigations of Garrod, Buzzard, and Ralfe, each carrying on by suc- cessive steps the study of this phase of the question. The last-named investigator, last in point of time as well, has formulated this theory in the following terms : The alkaline salts of vegetable acids (malic, citric, tartaric, etc.) are concerned! with the normal . transformation of the carbonates of the, blood; the actual factor is thus a chemical alteration in the quality Of the blood, a diminu- tion of its alkalinity ; that this follows the withdrawal df salts having an alkaline reaction,' such as the alkaline car bonates; that this scorbutic condition is the same as that produced experimentally by injecting acid into the blood of animals, feeding with acid salts, etc., viz., a dissolu- tion of corpuscles, purpuric spots, and other particular signs of the disease. The morphology of the blood is dis- appointing in so far as it fails to afford any sure index of the condition. While scurvy is a disease of diet and occupation, it is not a disease of country, race, sex, age, or season. It is found in all zones, among all peoples where the con- ditions favor it; it knows no sex, though males probably contribute a greater proportion to the statistical tables, for the evident reason that they are more usually sub- jected to the favoring conditions ; and in the matter of age it is met with from infancy to dotage. Naturally, it prevails in those countries and among those peoples whose observances of hygienic laws are " more honored in the breach," but it is found among civilized races as welt Institutions for the aged furnish cases occasionally, but on the whole it can be said that it is a disease of adult, life rather than of the extremes of age.. The winter season, for obvious reasons, adds to the number of cases when the disease exists in epidemic Or endemic form. As to occupation it was once thought to be a disease peculiar to the seafaring life, but it is found more on land than on the sea. > Clinical History. — A progressive upward and down- ward curve marks the course of a case of scurvy from its onset to its finish It has no definite attack, no crisis:. Unless the patient is.under conditions known to him to be causative,, as in the case of seamen On a long voyage, •the approach is without warning. The preliminary symptoms are those general signs of decreasing strength, mental depression, pallor, loss of flesh, anorexia, and perhaps some gastro-intestinal disturbance. This is gradually followed by the more characteristic features of the disease. The skin becomes dry, there is "pinch- ing " of the features, the complexion becomes of a dirty hue, for Want of a more applicable' term, and the gingival mucous membrane at the free margin becomes swollen and spongy. This is one of. the typical' features Of a case of scurvy. The gums bleed upon, slight pressure, appear bluish' in spots, and often ulcerations follow as the scorbutic condition progresses. The gums seem to der velop into this soft, necrotic texture around teeth that are broken! and decayed, but it is a matter of observation that in the aged who have lost their teeth and in children before the eruption of teeth., these gingival symptoms are practically absent. In severe cases the gums swell, and rising around the teeth partially cover them with a proliferated mass of foul growth, during which time the .teeth become loosened in their sockets and dislodg- ment may follow. The breath becomes intensely fetid as a result, the flow of saliva is increased, the salivary glands sometimes enlarge, and the tongue appears red and swollen. The eating of food is, under these condi- tions, not only a painful but a disagreeable function, and the. sufferer seeks liquid nourishment as a relief. This condition of the gums, which usually begins near the median line at ■ the incisors, is the first characteristic symptom, and hemorrhagic suffusions into the cutaneous, mucous, and deeper tissues is the second typical develop- ment of the disease. It is usually synchronous with or later than the gingival symptoms. These subcutaneous hemorrhages appear at first in the lower extremities, about the ankles, inthe form of petechial macules, vary- ing in size and most of them having a hair follicle in the centre. They resemble ecchymoses in some cases, in others purpura and similar cutaneous disorders. While they develop spontaneously they may be excited by blows or other injuries. The larger coalesced spots show chro- matic gradations of brown, green, and yellow at the periphery similar to the "black and blue" marks fol- lowing a contusion, but in scurvy there is, in the severe 79 Scurvy. Scurvy. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. hemorrhagic cases, a distinct elevation of surface upon which vesicles sometimes form. Ulcerations of an in- dolent type follow this and often destroy a large patch of cutaneous surface. The hemorrhages may be deeper- seated, giving to the limb affected a bosselated appear- ance, and when the intramuscular, the fibrous, and the subperiosteal tissues are involved the element of pain is introduced. These deeper hemorrhages constitute the one particular symptom of an advanced case of scurvy. At first they feel like doughy masses, pitting or yielding to pressure, but later the tissues lose this resiliency and, as the suffusions become more general and uniform through- out the muscular structure below the knee, the leg, when handled, feels as if it were made of wood. This scorbutic sclerosis, of which the text-books rarely make mention, may extend to the trunk and upper extremities, but it rarely invades the face or the scalp. The joints of the upper extremity, the wrist usually, may be oedematous, and this effusion may involve the serous surfaces, the pleura, pericardium, and sometimes the meninges. Hemorrhagic suffusions into the tissues of a mucous membrane are less constant, but, in the form of epistaxes, often resulting in syncope and exhausting anaemia, they are not so uncommon. The tissues involved do not re- spond to the usual remedies. When the intestinal mu- cous membrane is the seat of scorbutic lesions, there may be bloody stools, and in advanced cases the kidneys, spleen, bladder, and other internal organs may be in- cluded in this process. Other symptoms noted in well-marked cases are : artic- ular swellings, with pain and local febrile movement, and ulcerations of mucous surfaces, the cornea even being involved. Disintegration of recent callus has been re- ported, and other similar destructive processes, too nu- merous to mention, have been seen in advanced stages of the disease and are cited to show how profoundly the disturbed nutrition manifests itself in constitutional effects. While there are no marked symptoms involving the nervous system, the mental depression is noticeable and the patient seems to be indifferent to his condition and surroundings. Hemorrhages into the meninges may pro- duce convulsions or other abnormal cerebral manifes- tations. Among seamen the symptoms of hemeralopia and nyctalopia are not uncommon accompaniments. There is no constant type of temperature. In some cases it may be subnormal. The pulse is often rapid and always weak, and the heart action and respiration are affected by the slightest exertion. Haemic murmurs, common to all anaemias, can be detected. The urine is usually albuminous, of high specific gravity, decreased in quantity and of a high color. It may show the results of suffusion into bladder or kidneys. Obstinate diarrhoea, sometimes dysenteric in type, showing mucus and blood in the dejections, supervenes, and the loss of appetite and distaste for the foods that constitute the sufferer's diet, particularly at sea, soon give place to nausea and vomit- ing. These extreme conditions are not uncommon if dietetic relief does not intervene to turn the tide. The sufferer then presents a terrible picture, with sunken orbits surrounded by blackened circles, parted lips, and dingy yellow skin. He looks like a " breathing cadaver, " as one writer has graphically expressed it. Death from exhaustion, septicaemia, or some intercur- rent infection terminates these advanced cases that have not had treatment. Diagnosis.— When a number of persons come from a ship after a long voyage, presenting any of the charac- teristic symptoms above described, or others of a similar character but less pronounced, the difficulties in the way of diagnosis are not great. Single cases seen ashore, in the early stages, might easily be classed under the general diagnosis of "anaemia" or "debility " by one not familiar with the symptoms, or not on the lookout for a disease generally believed to be peculiar to sailors. Atypical cases may sometimes confuse the diagnosis, as in all other definite morbid processes, but the differential diag- nosis need only be established between it and a very few 80 The one which resembles it most in external appearance is purpura haemorrhagica, but this disease has none of the special gingival manifestations, the deep hemorrhages into the substructures, nor the hard brawny feel in the lower extremities. In purpura the macules are brighter and the skin not involved is of a cleaner hue, and as a further difference the articular involvement in scurvy is much less marked than in purpura. Peliosis rheumatica (SchOnlein's disease), nearly allied to pur- pura, may give rise to similar doubts of identity. A case recently reported by Surgeon Irwin, U. S. M. H. S., in a sailor, presented a concrete example of the confusion which may result. In peliosis the purpuric spots are distributed over the entire surface, in contradistinction to what is observed in scurvy; there is hydrarthrosis of the joints in the upper extremity with general muscular pains, and there may be oedema of the face and hands. The spongy condition of the gums does not obtain in peliosis, and the character of the eruption in scurvy differs from that of purpura haemorrhagica. Cases from ships hailing from ports where beri-beri is endemic may re- quire a careful differential diagnosis. In a suit for dam- ages entered by the sailors against the ship for scurvy, the defence raised this point in answer and the writer acted as expert witness at the trial. In the oedematous form of beriberi, where there is much emaciation, with swell- ing of the lower extremities, it is necessary to exercise careful scrutiny of the case with particular reference to conditions existing prior to presentation. There are no gingival symptoms in beri-beri and the oedema is differ- ent from the hard nodular feel in the legs of a scorbutic patient. It may be necessary, in cases involving litiga- tion between seamen and vessel owners charged with furnishing improper food, and thus causing scurvy, to be able to eliminate the question of the syphilodermata and specific infection complicating the case. Such alle- gations are usually resorted to by defendants in these cases. It will only be necessary to mention the fact, as the differential diagnosis should be easy for the medical attendant. Prognosis. — The mortality from scurvy should not reach five per cent., except in epidemics, military cam- paigns, or in exceptional conditions on shipboard. Dur- ing the civil war the rate was sixteen per cent., which considerably exceeds that obtained in our marine hos- pitals. In the ordinary cases met on land a favorable termination may be expected as soon as the proper meas- ures are instituted for correcting the diet. Recovery is naturally slow and sometimes weeks and months elapse, especially in the aged and feeble, before health is fully restored. In the grave cases seen on shipboard after long voyages, or after rescues from shipwrecks, the pa- tients may succumb to exhaustion, hemorrhages, or some intercurrent affection, but cases which seem hopeless from their general appearance quickly rally under appro- priate treatment. Pathology. — From what has been said of the nature of the disease it can be readily surmised that the pathol- ogy_>is unimportant. There are no characteristic ana- tomical changes, beyond the subcutaneous hemorrhages and suffusions into the deep structures and occasionally into the viscera. These have already been referred to. There may be serous effusions into the pleura or peri- cardium, but the peritoneum is not so affected. Par- enchymatous degeneration takes place in the internal organs. The stomach and intestines present the hemor- rhagic patches common to the cutaneous surface. The blood flows from these suffusions, when cut, as in a living subject. The spleen is soft and quite constantly en- larged. The condition of the buccal cavity is merely that which was previously observed at the bedside. Micro- scopical examination of the gingival tissues has revealed nothing worthy of special mention. Treatment.— Scurvy is a preventable disease, and therefore the question of treatment partakes of two phases, the prophylactic and the curative. The first may be applied in the case of ships about to proceed on long " deep-sea " voyages, whalers bound for the frozen REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. Scurvy. Scurvy. sea, merchant ships sailing "round the Horn," or in the case of large institutions for the poor and indigent in which, for economical reasons, the diet must be restricted to the actual necessities. The United States statutes contain certain requirements respecting these matters. One relates to the supply of lime juice and vinegar (Sec. 4, 569), which must be provided on voyages across the Atlantic or Pacific oceans or around Cape Horn or the Cape of Good Hope. The other (Sec. 4, 12) defines what shall be the daily minimum of articles and quantities of food supplied, a not altogether satisfactory or scientific table. As each municipal institution for the care of the poor has a medical officer in attendance it will be incum- bent upon him to advise the managers as to the quality and variety of food required for the proper nourishment of inmates, in order to avoid the occurrence of scorbutic symptoms among these ill-conditioned people. This can be accomplished by a judicious variation in the daily diet schedule. This diet should include not only fresh vegetables in season, but, what is equally to the point, fresh meat. In all almshouses there will be found a large proportion of persons laboring under the depress- ing and degrading influences of such places, persons in feeble condition or advanced life, who may confine them- selves to a portion of the prescribed diet for a long period, and in whom scorbutic symptoms are inevitably set up. Osier cites a case of a woman who subsisted for many months on bread and tea, and it has been noted that in logging camps and among charcoal burners, where a diet of bread, molasses, and bacon is staple, scurvy will be found. The old maxim that " variety is the spice of life " is the keynote to the prophylaxis of scurvy when consid- ering the dietetic question. It is not quantity nor qual- ity, but variety that is the inviolable canon in the ali- mentation of mankind. Scurvy is not a disease of starvation, it is nature's revolt against lack of dietetic balance. None of the professional "fasters" ever de- veloped the characteristic signs of the disease. The therapeutic indication in the curative treatment of scurvy is one of dietetics rather than of medication. When the patient is first seen he should be removed from the environment responsible for the condition, whether ship, house, or room, and given such benefits as arise from change of air and surroundings. If possi- ble, a warm bath should be given and clean clothes and a clean bed provided. These attentions are possible if the case can be removed to a hospital. The first symp- tom that will claim attention in an advanced case is the spongy or bleeding condition of the gums and the conse- quent fcetor of the breath. The relief of this is a prelimi- nary to attractive alimentation and may be accomplished by the use of any of the mild antiseptics in the form of gargles and mouth washes. It is not necessary to enu- merate them. The juice of a lemon, which possesses some astringent as well as other useful properties, is a simple and eff ecti ve aid in this process. More pronounced astringents, as catechu or krameria, may be employed by brushing them on the spongy mucous surfaces. Alum may be applied in the form of a powder to small ulcera- tive patches, and a weak solution of lunar caustic, pen- cilled with a camel's-hair brush, enables the operator to reach such surfaces between the teeth. Pood is to be administered cautiously at first, and the first indication is the exhibition of fresh vegetables in the form of a strained soup. The condition of the gums and teeth may not permit the process of mastication. Lemons or limes can be given in the intervals between regular meals. Spinach, boiled, is an excellent form of vegetable, possessing highly nutritious qualities and hav- ing the advantage of softness in consistence. Sauerkraut, and vegetables used as " greens, " with vinegar, are also valuable variants. To this basis may be added, as a change, fresh milk, and well-cooked beef, in judiciously graduated quantities. Occasionally the vegetable diet may be distasteful, paradoxical as it would seem, but it must be enforced until the condition of the patient shows its- good effects in an improved color, increased strength, and general resumption of normal conditions. That a Vol. VII.— 6 plan of tonic treatment is indicated need hardly be said. Iron in some form, preferably the citrate, or the tincture of the choride, is an excellent medicament in scurvy. The use of potassium in one of its salts, to replace theo- retically the loss of the vegetable potassium, as advocated by Garrod, an early authority on the disease, has not given very satisfactory results. If nausea and vomiting, due to a distaste for food previously constituting the patient's diet, be present they will soon cease after the proper ali- mentation is instituted ; but if they continue they may be stopped by such gastric sedatives as bismuth, hydro- cyanic acid, or the carbonated waters. The last named are preferable. If digestion be feeble, the bitter tonics — gentian, quassia, or strychnine — may give a necessary tone to this function. Constipation and its opposite con- dition, either of which may be present, are to be treated with care. The changed diet should be allowed to op- erate for a few days as a natural stimulus to normal action. According to my experience it may be expected to act in this way. Diarrhoea, if persistent, needs some astringent, but constipation should cause but little anxi- ety. Intestinal hemorrhages require more active han- dling, and ergot, iron, lead acetate, or any approved haemostatic must be exhibited. Calcium chloride can be advantageously given in doses of gr. xx. t.i.d. for this condition. The stiffened joints should be treated with massage and passive motion. Gentle friction over the ecchymosed regions and at points where there are signs of deeper suffusions, will prove of benefit in promoting absorption. All treatment, however, beyond the dietetic, may be classed as symptomatic. ' Infantile Scorbutus. — General Considerations. — "Within the past two decades there has been added to the list of diseases, for the special consideration of pe- diatrists, the scurvy of infants, following prolonged artificial feeding. To a number of English physicians, notably Dr. Barlow, who reported thirty-one cases in 1883, our knowledge is originally due, and from this physician the disease has come to be known in medical literature as "Barlow's disease," from its first reporter. Since that period it has been the subject of special study by observers in Europe and America, and scarcely an issue of journals devoted to pediatrics is wanting in some reference to the disease, its etiology, pathology, or clinical history. The American Pediatric Society con- sidered a lengthy report on the subject in 1891 made by Dr. Northrup, and among the conclusions of the au- thor was this: "It is a significant fact that the country which furnishes most of the literature of scorbutus in children is the same which is posted from end to end with advertisements of proprietary foods." Indeed it may be said that the appearance of this disease has a close relation, chronologically, to the development of the in- dustry of artificial feeding of infants and the growth of the sentiment for sterilization following the diffusion of knowledge concerning bacteria. Etiology. — Like scurvy in the adult, this disease of infancy is due to the continued use of an artificially pre- pared food which lacks some essential element required for nutrition. It is a disease found oftenest among the children of the rich and well-to-do, because in their homes are found the mothers who cannot, or will not, nurse their children, and who are able to provide themselves with prepared infant foods and the apparatus for the sterilization of milk. It may be stated as a general proposition that infantile scurvy is a disease of affluence and rachitis a disease of poverty, for though having some general resemblance to each other, these affections are distinct. As scurvy is a disease due to improper feed- ing, it may be further said that neither age, sex, race, nor season has any causal relation to its manifestation. It may occur at any age, but is oftenest found in infants between the eighth and twentieth months, or during the period of the eruption of the teeth and before the child is put on the enlarged diet which follows the ability to mas- ticate. Children who are fed on the bottle later than this may also have the disease. In nearly all the cases that have been reported the patient has been fed on some one 81 Seasickness. Seasickness. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. of the following foods : Proprietary or cereal foods, con- densed milk, peptonized milk, sterilized milk, any of the cereals (as barley water), or milk too much diluted with water. Of these causes it seems pretty safe to say that the sterilization processes enjoined by many physicians and adopted by the laity as a tribute to bacteria, in the preparation of these various foods, is responsible to a great extent for the conditions which follow. From ob- servations made in cases which have developed in infants it has been found that the scorbutic symptoms will begin to manifest themselves in from six to eight weeks after the institution of the improper diet. As in scurvy of the adult the exact etiological factor is still undetermined, but it would seem that fresh milk when ingested possesses antiscorbutic properties not unlike those possessed by the vegetable elements when administered to adults. Clinical Symptoms. — An infant fed on artificial food, and especially on sterilized cow's milk (brought to 212° F.), will begin to show, after six weeks or more of this diet, the general signs of systemic disturbance, pallor, restlessness, disinclination to be moved. This is followed by particular evidences of pain in the lower limbs, usually localized in the femur, and in an increasing im- mobilization of the legs as the disease progresses. The pains grow more intense, the knees are drawn up, held motionless, or rotated outward and fixed, simulating paralysis. It will be seen that there is a cylindrical swelling of the lower end of the diaphysis of the femur, due to hemorrhagic suffusions into the subperiosteal space, either in one or in both thighs, and as a result in advanced cases this condition is often accompanied by fractures of the bone underneath. Swelling and soften- ing of the gums presents the typical scorbutic feature almost S3'nchronously with the above condition, but this manifestation is not usually seen in infants in whom some of the teeth have not erupted, and this gingival symp- tom is usually most pronounced about the incisors or about the teeth that may have pierced through. The condition of the gums is the same as in adult scurvy, with this exception : If teeth are in the upper jaw and not in the lower, the latter will not show the spongy and bleeding and ulcerated condition surrounding teeth that are present in the former. This symptom is usu- ally followed by another characteristic scorbutic sign- subcutaneous hemorrhagic suffusions showing purpuric spots and coalesced macules of greater or less size and the appearance of multiple tumefactions of the deeper tissues. The picture is not so different from that of the adult disease, viz., the ashen hue, the foul breath, the circles about the eyes, the swollen, tender joints, and the listless mental condition. There is no temperature characteristic of the disease unless it bo subnormal. Examination of the blood affords no more satisfactory results than in adult scorbutus. Hemorrhages into the cavities of the body occur. Diarrhoea is more frequent than constipation. Diagnosis. — From the description above given the rec- ognition of this disease in a developed case should not be difficult. It may be confounded in the early stages with rheumatism, rachitis, purpura, acute anterior polio- myelitis, infantile paralysis, and possibly syphilis. The first named may offer the greatest field for error. In rheumatism the joint itself is affected; while in scurvy the tissues about the joints, especially the knee, are involved. In scorbutic hemorrhages the blood escapes practically always into the diaphysis of the long bones. With proper protection of the femur the knee-joint can be moved without discomfort in scurvy. The differen- tiation from purpura is made in the same way as it is in scurvy of the adult type. In purpura the macula- tions are more evenly distributed over the entire surface, in scurvy the lower limbs are mostly affected. In in- fantile paralysis and poliomyelitis the immobility of the limbs is due to palsy of the muscles, while the failure of movement in scurvy is because of pain. The disease may be distinguished from rachitis by the absence of the rosary and by the typical skeletal signs of that dis- ease. The characteristic scorbutic signs in the gums 80. should always enable the observer to exclude rachitis from the problem. Dietetic treatment will usually set- tle a diagnosis in a few days. Other diseases to be borne in mind are haemophilia, erythema nodosum, leukaemia, and local periostitis. Pathology. — The special lesions found post mortem are those relating to the hemorrhages occurring in the course of the disease, but differ in no way from those observed in the adult type. Up to the present time no character- istic signs have been found which add to our knowledge of the pathology of the disease. Treatment. — Being a preventable disease it has its prophylaxis as well as its cure. The first relates to the use of proper food. If a child must be given artificial alimentation, it is necessary that it have the nearest suc- cedaneum to human milk that can be readily procured. This to a certain extent involves the whole question of infant feeding, which cannot here be considered. This much may be said, that cow's milk is the best substitute because the cheapest and most easily procured, as well as because it contains all the necessary elements. The proportions of the constituents differ from those of hu- man milk, but a scientific effort to " follow nature " has not been productive of happy results. Properly diluted with water and raised to a moderate degree of heat, not over 170° F., for ten or fifteen minutes, cow's milk is the most available and natural food for infancy. This heat will effectually dispose of all bacteria that need give cause for anxiety. The " pasteurization " of milk renders it truly a sterile product — a dead liquid — in which either the antiscorbutic properties are rendered inert or the low proportion of proteids favors the characteristic signs of scurvy. The effect, upon milk, of heat sufficient to sterilize it, is not entirely understood. It is a delicate complex form of protoplasm, and the effects which " pasteurization " produces upon the caseinogen, nucleins, and the calcium salts by which their combinations are disturbed, have undoubtedly to do with their efficiency as antiscorbutic agencies. This much has been learned by practical experience and points the way to the pre- ventive treatment of the disease. The curative treatment is upon the same order as that of the adult type — the restoration of the food that the infant has been deprived of, viz. , fresh milk in properly diluted form. This milk may be given in alternation with a teaspoonful or two of orange juice every hour throughout the day. Raw beef juice, salted, may be used for a change, and barley water can afford a satisfactory alternative. But the main reliance must be upon fresh milk fed with due consideration to the condition of the infant's digestive apparatus. All other forms of treat- ment are symptomatic and need not be detailed. As in the adult type the most desperate cases, so far as may be judged from external signs, recover rapidly when proper food is furnished. Charles & Banks. SEASICKNESS,. or NAUPATHIA (wri*, a ship; ™&> f , sickness. French, Mai de mer ; German, Beekranklieit ; Dutch, Zeeziekie; Spanish, Mareo ; Italian, Maledi mare), is the name applied to a definite syndrome group that occurs usually in persons on board a vessel at sea — but also occasionally when the subject is in a rapidly moving , railway or trolley car, on the back of a camel, in a bal- ' loon, an elevator, a swing, a merry-go-round, etc. — and of which nausea and vomiting are the most marked phenomena. It is said that not more than five per cent, of human beings are entirely exempt from it; but while I have no statistics to offer, this proportion seems to me much understated. The same individual may differ in his susceptibility at different times. As a rule, those who make frequent voyages become acclimated; but some persons are always sick on board ship, even in smooth weatiier. As a rule, weather and the-motion of the ship make considerable difference in the number of sick persons on a vessel, and in the severity of the attack in the individual. Age has some influence upon resist- ance. Very young children are rarely affected, and children below the age of puberty are not nearly so REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Seasickness. Seasickness. susceptible as adults. Lower animals differ in their sus- ceptibility to seasickness; dogs, horses, cows, sheep, and chickens have been affected; but hogs, ducks, and geese are said to escape, as a rule. The attack varies in both degree and duration, according to the idiosyncrasy and the physical condition of the individual. Merely uncom- fortable sensations may be experienced, or the condition may be one of mental and physical collapse. Seasickness is not in itself dangerous to life — very few deaths having been recorded — nor, on the other hand, is it beneficial, as is sometimes stated. Symptomatology. — Definite symptoms arc presented by this affection. Abnormal increase of appetite may be the first sign, but anorexia — even active disgust for food — is more common. Headache is the rule, and is in many cases attended with a sense of fulness or congestion. It is often most intense, and usually constrictive, over the forehead or temples ; sometimes the severity is greatest on the top or in the back of the head. Usually there are pain and a feeling as of pressure in the eyeballs. Often there is pain in the back of the neck. Soreness in the back and neuralgic pain in the extremities may also be present. Nausea and vomiting are, as a rule, most obstinate. Their onset may be preceded by general chilliness with pallor of the face and lips. Ptyalism occurs at times, and there may be a foul taste in the mouth. Constipation ordinarily accompanies the gen- eral disturbances; diarrhoea is less frequent. Chilliness and flashes of heat are sometimes complained of. Men- tal depression, despondency, and even despair are fre- quently observed. In addition there may be complete loss of will power and of the faculty of concentration. The pulse presents a diminished resistance, being small, feeble, and easily compressed. The skin is pale, cold, clammy, and often moist. The urine is diminished in quantity. Causation. — Numerous theories have been advanced as to the cause of seasickness. All writers agree, how- ever, that the complaint is aggravated by the physical and mental fatigue caused by the preparations for the voyage, by the emotional excitement of parting, by previous imprudences in diet, by constipation, and by want.of proper food. The cause of naupathia is believed by some to lie in disorders of certain senses. It is given as visual disturbance caused by the constant mobility of surrounding objects; irritation of the semicircular canals caused by the frequent and varied movements of the ship, and confusion of the muscular sense, or a disturb- ance of the feeling of the relation of the body to sur- rounding objects, caused by the unstable conditions prevailing on board a vessel. Irwin regards seasickness — or motion seasickness, as he calls it— as a disturbance of a supplementary special sense whose function is to determine the position of the head in space and to govern and direct the wsthetico- ldnetic mechanism by which is maintained the equi- librium of the body. He holds that motion produces sickness by disturbing (a) the endolymph in the semicir- cular canals, (b) the viscera in the abdomen, and possibly (c) the brain and the subarachnoid at its _ base. The true primary cause of seasickness he believes to be irritative hyperemia of the semicircular canals. By some the stomach has been regarded as the seat of the trouble. The view taken is that by the shaking of the contents cf the stomach digestion is stopped and fermentation sets in. the undigested fermented food being thrown off bv an effort of nature. According to this theory the headache, depression, and vertigo are due partly to the absorption of bile, or of some or many toxic products of metabolism or of fermentation, into the cir- culation, and partly to irritation of the pneumogastric nerve terminals. Some suppose that the play of the diaphragm and abdominal organs, caused by the move- ments of the ship, induce spasms and convulsions of the stomach. Another theory attributes the symptoms to a severe intramolecular shaking and irritation produced in the cells of particular organs by rapid movements arising from sudden change of duection of motion. The direct mechanical effects produced on the nervous tissues by the movements of the ship are given by many as the cause of seasickness. These include repeated slight con- cussions of the brain produced by its being shaken up and down in its bony case ; a centrifugal jarring of the brain as a result of motion along the two arcs of a circle described by the axis lines of a ship; shocks inflicted upon the brain and spinal cord by the violent flux and reflux of the cerebrospinal fluid, induced by the move- ment of the vessel. Beard believed naupathia to be a functional disturbance of the central nervous system, the cause being purely physical or mechanical — a series of mild concussions — the agitation of the nervous system by the movements of the ship. Other theories ascribe the cause to effects produced on the nervous system by disturbances of the circulatory apparatus. It has been supposed that the irregular variations of barometric pressure pro- duced by the rising and falling of the waves cause oscillations of the column of blood within the larger vessels. Seasickness has been attributed also to sudden and recurring changes of the relations of the fluids to the solids of the body, both of which obey the law of gravity when the body is subjected to alternate movements of ascent and descent ; the blood, however, descending more rapidly and ascending more slowly than the solids. Pollarin believed the condition due to the lessening of the ascending force of the blood in the aorta and in the arteries springing from it, caused by the movements of the body and resulting in ansemia of the brain. Wallaston, on the other hand, ascribed it to cere- bral congestion. Chapman held that the proximate cause of seasickness consists in an undue amount of blood in the nervous centres along the back, and especially in those segments of the spinal cord related to the stomach and the muscles concerned in vomiting. Skinner believes that the motions of the ship cause movements, slight or considerable, and repeated displacements, collisions, and stretching of various organs of the body, especially of the abdominal organs, and unequal and alternate increase and lessening of pressure exerted by the column of blood on the walls of the arteries and veins. This starts a reflex nervous act, an inhibitory influence, causing a paresis of the cardio-accelerator and vaso-constrictor centres. Thus are brought about enfeeblement of the heart's action and frequently a diminution in the number of cardiac pulsations, and a consecutive loss of vascular tone with relaxation of the walls of vessels of medium calibre. This results in a general lowering of the arterial blood pressure, which is the cause of naupathia, giving rise to ansemia of the medulla, ansemia of the braiu, anaemia of the skin, diminution of the blood pressure in the kidneys, and the diminution or the absence of action of the sympathetic nervous system upon the unstriated fibres of the intestine and of the arteries, and also upon the intracardiac nerve ganglia. A vicious cycle is thus established. Gihon considers seasickness a neurosis, and says that while the onset of mild attacks may determine a tem- porary increase of blood in the cerebrum, it is certain that the lessened arterial tension due to the vaso-motor disturbance later deprives the nerve cells of their proper stimulus, and the consequent ansemia of these centres results in weakness of the heart and dilatation of the vessels. Even miasmatic intoxication has been made responsible for seasickness (Lemonas). The theory that seems to me the most plausible is that which attributes to rupture of labyrinthine compensation the principal phenomena; thus partially allying the con- dition to mountain -sickness and aeronauts' sickness, in which this factor plays a subsidiary part. Concussion of nerve elements probably adds to the sum-total of disturb- ances; while auto-intoxication is added as a result of the, failure of digestion and derangement of metabolism. Lowered vascular tone is both a symptom and a cause of other symptoms. Psychopathy (morbid suggestion') is not to be excluded entirely, but is not in itself a sufficient explanation. 83 Seasickness. Sea Voyages. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. PrtoniYLAXTS and Treatment.— Different forms of treatment— physical, physiologic, and medicinal— have been recommended, in accordance with the various theories as to the cause of naupathia. The exciting cause in every case being the motion of the vessel, a stateroom should be selected near the centre of the vessel, away from the engines. An inside room is said by many to be preferable, but in my opinion the lack of ventilation more than counterbalances its supposed advantages. _ As prophylactic measures, it is advised that all preparations be concluded at least twenty-four hours before embark- ing, so that the system may not be exhausted by over- work and want of sleep, and that as hearty a meal as possible be eaten before going on board. Those espe- cially liable to seasickness are told to go to bed before the vessel gets under weigh, having previously arranged within easy access such things as may be needed for the first day or two ; to eat regularly and heartily, but with- out raising the head for at least one or two days; to take a mild laxative on the first night out and to keep the bowels open ; and, after being able to go on deck and to the table, not to rise in the morning without first eating something. If the sea should become unusually rough, they are to go to bed before getting sick. Some have advocated a spare and dry diet, one full meal being in- dulged in, aud soup, pastry, milk puddings, and sweets being avoided. I have seen good results apparently due to the following prophylactic regime : (1) A calomel purge followed by a saline, one week before sailing, and again two days before sailing. (2) A saline irrigation followed by complete rest, the morning before sailing. (3) Saline laxatives or enemas daily for the first few days on board. (4) Spending all the time possible on deck. Those very susceptible should maintain a reclining post- ure in a steamer chair, but out of the direct sunlight. Those but slightly affected should try to move around from time to time, walking a little more each day. (5) Taking for the first day or two light, easily digested food at short intervals. (6) Sponging or bathing daily with cold water, or with hot water preceded by cooling of the head and neck and followed by a cold friction rub or shower. (7) Taking minute doses of picrotoxin (gr. y^ hourly) for ten' hours daily during the week preceding the voyage, and for two or three days at sea. I should now advise instead epinephrin (commercially known as suprarenalin) in doses of from gr. -fa to gr. ^, absorbed from the tongue. For this purpose a fraction of a grain of sugar of milk may be added, and either powders or tablet triturates be dispensed. It is usually advised that the horizontal position be assumed. Various physical expedients have been tried to lessen the motion of the vessel but without success. The twin ferry-steamer, the Calais-Douvre, the Bessemer suspended saloon, swinging state-rooms, swinging berths and bunks, and the always upright easy-chair, fauteuil- de-mer of Dr. Neveu-Derotrie, have all proved failures. Various preparatory exercises to be practised by those intending to go to sea have been suggested. Swinging, turning around upon one foot, the use of rocking-horses, oscillating planks, gyratory chairs, and the like, have been advised. Dr. Hewitt devised a mirror, so hung as to swing on its oblique axis over a swinging platform provided with a seat and movable at will up and down, from side to side, backward or forward, or in a combina- tion of these movements. The person contemplating a voyage was advised to use this contrivance daily for some time before tempting the winds and waves. Various expedients based on the visual theory are recommended. Thus, patients are instructed to keep their eyes closed or covered; to wear smoked glasses or blue or red glasses; or to fix their eyes on some object away from the vessel. The wearing of red spectacles has been ad- vocated on the theory that the effect of the color on the blood-vessels of the brain would be to send the blood to the brain, relieving a cerebral anamiia. To lessen the irritation of the semicircular canals, Dr. Minor suggests dropping cocaine in the ear. To keep the intestines quiet, to support the abdomen exhausted by incessant retching and vomiting, to determine the flow of blood to the head, or to provide a substitute for the stimulus and distention of food, abdominal compression by means of a bandage, handkerchief, towel, or napkin has been advised and is really useful. If the abdomen be hollow, a soft folded blanket may be fitted into the depression. Inflating the lungs and holding the breath as long as possible have been suggested as a means of fixing the diaphragm. Hovent, indeed, advocates systematic inhalation and exhalation against pressure by means of my pneumatic resistance valves. In my own person the experiment was unsuc- cessful. The dietetic management usually recommended after the onset of seasickness is that a moderate amount of easily digested food be taken at short intervals. Beard says that one should keep something in the stomach all the time, if possible. Thin soups, broths, and gruels usually may be given. Junket, matzoon, kumyss, clam juice, beef juice, curry, preparations of blood, and pre- digested preparations of milk, beef, peptones, and the like can often be taken in small quantities, even after nausea and vomiting have occurred. Many experienced ship surgeons advise against the exclusive or excessive use of liquid food and prescribe solids or semi-solids; they believe that liquids encourage vomiting. Some writers recommend mulled wine, grog, Curacoa, eau de menthe, iced dry champagne, cider, and brandy. Acid or effervescing drinks, such as seltzer, ginger ale, and sweetened water, with the addition of lemon j uice or a little citric or tartaric acid, are often refreshing when taken in moderation. Draughts of ice-cold water, or pieces of ice held in the mouth, may give comfort. Coffee and tea as hot as possible, and in small doses, are sometimes soothing and invigorating. As curative agents various forms of counter-irritation have been employed, the commonest being a mustard leaf over the epigastrium. Electricity has been applied, chiefly as faradization of the epigastric and hypochon- driac regions, in some instances combined with the paint- ing of the parts with a solution of atropine sulphate for cataphoretic effect. Chapman advocated the application of an ice-bag to the spine, believing that thus he could lower the temperature of the spinal region. Baruch, however, asserts that cold applied to the surface of the body, instead of penetrating deeply, calls into action the heat-regulating machinery of the body for the purpose of resisting the invasion of cold into the interior. The success Chapman met with may have been due to stimu- lation of the spinal centres with increase of vascular tone. The spinal coil would probably be more comfort- able than an ice-bag and more easily arranged. If the benefit lie in the elevation of depreciated nerve tone, the best hydriatic application would appear to be the douche. The Winternitz combination compress, so efficacious in cases of obstinate vomiting, should be of service in sea- sickness, though it will rarely be available. It consists of a stimulating cool trunk compress enclosing an epigas- tric coil through which circulates water at a temperature ■ of from 122° to 132° F. The cold wet compress at first produces an anaemic condition of the skin beneath, with contraction of the cutaneous vessels and irritation of the peripheral nerves. Reaction quickly follows with tonic dilatation of the vessels, the part covered by the coil be- coming hyperoamic. Dr. Edward Miller, in 1814, recom- mended the warm bath alone, or alternating with the cold bath, friction of the skin with oil and camphor, or dry friction with powder of mustard. Various drugs and classes of drugs have been em ployed to meet certain supposed indications. Laxative treatment is usually recommended, and should be commenced as early as two weeks previous to the night before the con- templated journey. Podophyllin, aloes, rhubarb, and the salines have been used. Drastic cathartics, however, should not be administered. Various sedatives, analge- sics, and hypnotics have been employed. Bromides (am- monium, potassium, sodium, strontium) are often given in doses of from ten to thirty grains three times a day. Beard, advocated mild bromiziition and prescribed large doses 84 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Seasick nese*.. , Sea Voyages.. of sodium bromide for three or four days before starting, keeping this up while at sea, until there is well-grounded reason to believe that all danger is over. Chloral hy- drate, in doses of five or ten grains, has been used alone or in combination with the bromides. Chloroform is sometimes employed. Charteris prescribes "chloro- brom," a solution of chloralamid and potassium bromide, for three nights in hypnotic dose — a tablespoonful for women and a tablespoonful and a half for men, or a tea- spoonful every ten minutes until the full dose has been given. Nelken gave half a grain of morphine twice a day. Cannabis indica, in doses of half a grain, has been em- ployed. Antipy rin has been given in doses of from five to fifteen grains. Chloralamid, chlorodyne, paraldehyde, sulphonal, and the like, have also been used. Person- ally, I have seen benefit only from the bromides — of which strontium is the best — and morphine when needed. Certain so-called neuro-muscular agents have proved useful. According to Skinner, they increase the activity of the nerve cell and of the unstriated muscular fibre, as well as that of the striated, and thus cause an elevation of the arterial blood pressure. The theory is of dubious worth, but the practice is useful. Cocaine, caffeine, strong black coffee, thin and strong infusion of black tea constitute this group. I have seen much good from fluid extract of erythroxylon coca and from wine of coca. Other remedies that act in a similar manner are the- obromine, guaranine, kolaine, and preparations of kola. Strychnine and atropine have been used. Skinner em- ployed them simultaneously in order to raise the blood pressure by acting upon the nervous centres and the un- striated muscle fibres. On account of the frequent vomiting in seasickness he preferred the hypodermic method of administration, giving to an adult from 0.5 mgm. to 1 mgm. of atropine, and 1 mgm. of strychnine, dissolved in mint water. This he repeated in two hours if the patient was not well, and even again two hours later. He never exceeded three injections in one day. Amyl nitrite has been lauded by some writers. I have seen benefit from strychnine arsenate, 0.5 mgm. (gr. y^g-) hourly by the mouth, and also from picrotoxin — which acts' like a combination of strychnine and belladonna — in about the same dose. Crude adrenal preparations have failed in my hands, but it is probable that epi- nephrin absorbed from the tongue may be useful in many cases. Agents used for their supposed effect on the stomach are dilute chloroform, hydrocyanic acid, tincture of iodine in drop doses, cerium oxalate, cocaine, sodium bicarbonate in doses of ten to twenty grains, creosote in drop doses given every hour, eucalyptus rostrata, the digestive fer- ments, the dilute mineral acids, "Worcestershire sauce in teaspoonful doses, and preparations of Peruvian bark, calumbo, and quassia. The older writers gave emetics on the advent of vomiting, using infusion of chamomile, peppermint or ginger, or even sea-water. Lemonas recommended quinine to combat the hypothetic miasmatic intoxication. I have seen no recommendation of specific serum — neither of an antitoxin from an acclimated hu- man being or lower animal, nor of an artificial combina- tion of chemical salts ! As a rule, if patients keep on deck, keep their bowels clean, do not overeat, sponge or bathe daily with cold water— or with hot water, if preceded by cooling of the head and neck and followed by a friction or by a shower or general douche of cold water — and are subjected to cheerful rather than to depressing suggestion, they will recover quickly without medicines. I have seen attacks cut short by a calomel purge followed by thorough saline irrigation of the bowel. Solomon Solis CoJien. SEAL, GOLDEN. See Hydrastis. SEA VOYAGES.— Therapeutically sea voyages may be divided into three groups : 1. A voyage incidental to a change of residence or climate, or to a business or pleasure trip. Voyages of this class are usually, though not always, short, and apart from perils or discomforts of the particular voyage, need, to be studied only from the viewpoint of possible counter- indications in the special case of a weak or delicate per- son, or one who has borne previous sea trips badly, or of. an invalid affected with some lesion rendering the voyage hazardous. Such counterindications will be mentioned in the general discussion. 2. A voyage undertaken as a restorative measure in the; case of an individual patient. Voyages of this class are to be studied from all possible viewpoints, meteorologic, geographic, climatic, epidemiologic, therapeutic. The time of year,' the special trip, the ship, the disease, the patient and his companions, must be given careful consideration, and indications and counterindications. weighed against each other. Thus, voyages around Cape Horn in the winter of the southern hemisphere are to be avoided for invalids; and similar questions of route and season are always to be examined in detail. In this article space will not permit more than casual allusion to a few special voyages. 3. A voyage forming part of a salieme of climatic or other treatment. Voyages of this class stand midway between the other classes, and certain discomforts or other counterindications, not otherwise permissible, may be outweighed by the benefits expected from the meas- ures to which it is a necessary introduction. Ocean Climate.— The climate of the open sea possesses characteristics not to be found elsewhere: a peculiar equability of temperature due to absorption of thermal rays and surface evaporation in the day, and to convec- tion with surface heating and diminished radiation at night; an abundance of light; a favorable degree of relar tive atmospheric humidity (the mean being 73.5 per cent.); and freedom of the air from dust, microbes, and other impurities. It is not necessary to call upon the presence of chemical factors in the atmosphere, ozone, iodine, or salines, to explain its beneficial influence; yet independently of chemical analysis the sense of smell finds an agreeable quality in the sea air, which doubtless indicates properties acting in an.equally acceptable man- ner upon all nervous tissues, and possibly upon all cells. The breezes are always refreshing, and except in certain regions of latitude or current the midday temperature seldom exceeds 85° F., and is usually very much less. When the temperature is high upon the sea it is less dis- tressing than an equal degree of heat upon the land ; thus, at the tropics it is rarely oppressive even in the absence of wind. Similarly cold is often better borne at sea than on land, though from a therapeutic viewpoint extremes of either heat or cold should be avoided. Against these qualities the depressing and distressing effects of storms — to say nothing of their dangers — must be taken into account. Factors Other than Climatic. — The prolonged mental rest and the complete change of surroundings incident to a sea trip of moderate length are factors of no mean value in the sum total of restorative effects. On the other hand, in very long voyages, the monotony may he^ come wearisome, and this contingency must be provided against. Ship, time of year, proposed voyage, and cost may not always correspond to desire. Light' and air, while abundant and pure on deck, are not always so in the cabins. The food may not be suited to the needs of invalids, and the absence of fresh milk, fresh fruits, fresh vegetables, is often a serious . drawback. Some individr uals are peculiarly susceptible to seasickness, and others suffer with deranged metabolism during the greater part of the trip. Women generally feel the discomforts of life on shipboard more than men do, and can seldom be advised to take prolonged voyages. It is necessary in every case to exercise great care in the selection of ship, master, and route, to inspect the sleeping cabins and general accommodations, and to be sure that the die- tetic arrangements are good. Other things ibeing equal, well-equipped sailing vessels are to be preferred to steam- ers for therapeutic voyages. There should always be a trustworthy ship's doctor, and in many cases the invalid must be accompanied by a special attendant or a physi- 85 Seborrboea. Seborrheea. REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. cian. When the patient owns a seagoing yacht, most difficulties vanish ; and Sir H. Weber has suggested ships, specially built and equipped as ocean sanatoriums, to be sent on well-selected voyages according to season. In the consideration of seasickness, the general precau- tions necessary to therapeutic voyages were considered. Here it may be emphasized in repetition that the pure air of the deck is preferable to the stuffy atmosphere of cabins ; that exercise is necessary ; that exposure to the sun is usually beneficial; that the skin should be cared for by regular and systematic baths, frictions, etc. In addition to the care necessary in choosing vessel and cabin, the provision of congenial companionship and of sources of intellectual interest as the inclination to men- tal activity returns, demands attention. Indications. — Short voyages of from five to twenty days are useful chiefly to give mental and physical rest and recreation, and to prevent relapse or other accident after convalescence from depressing affections, as influ- enza. Voyages of moderate length, twenty to sixty days, are sometimes followed by strikingly good results in cases needing more prolonged rest, as in breakdowns from overwork, irritable conditions of the nervous sys- tem, even actual neurasthenia when the patient has good resisting power. In certain cases of asthma, in the con- ditions termed "scrofulous," in chronic tendencies to "catching cold," in suspected or actual pulmonary tuber- culosis, such voyages are often beneficial. In chronic catarrhal conditions of the upper air pas- sages, in chronic rheumatic states, and sometimes in chronic rheumatoid arthritis, voyages to warm climates, as a winter trip to Mediterranean or Caribbean waters, may be advised. Hay fever has been reported to have been observed at sea, but the occurrence is so rare that its possibility may be disregarded and the general tonic effect of the ocean climate upon those susceptible to this affection is highly desirable. Some chronic forms of diabetes mellitus in middle-aged or elderly patients are ameliorated by ocean trips, especially those to warm cli- mates in the winter. Prolonged voyages, three months or more, are to be advised only when the patient is known to be a good sailor, is not too severely ill or too weak to undergo some discomforts, and has a fair degree of resisting power, as well as good digestive and eliminative functions. The special trips of three and four months to north European waters in the summer and to Mediterranean and Oriental waters in the winter, made by well-equipped vessels and including in their itinerary stops at various important ports are, however, to be classed therapeuti- cally with voyages of moderate duration, and are espe- cially to be commended to convalescents and those need- ing rest and recreation. Long voyages on the open sea, as to Australia, for example, are to be advised chiefly for those who enjoy the sea, for dipsomaniacs and drug slaves, and in cases of pulmonary tuberculosis. It is especially in suitable cases of pulmonary tuberculosis that well-chosen voyages are to be urged, sometimes as a means of recovery, sometimes as a means of palliation and of prolonging life. Some patients can "rough it" on sea and land with benefit ; others must be carefully protected. The stage of disease, too, and the general characteristics of the patient make considerable differ- ence. Hence general rules cannot be laid down. Cer- tain main factors, however, may be presented. In febrile cases the temperature usually subsides after a few days upon the sea. In cases which show much general ten- dency to recovery, but in which limited areas of persistent activity remain, the local processes diminish and finally cease under the influence of the aseptic sea air and the general stimulation of nutritive processes. In cases of crethic temperament, unsuitable for mountain cures, especially those with a tendency to excessive cardiac action at altitudes, the sea exerts a beneficial sedative in- fluence. No other measure is of equal value in early cases an robust males, especially in young men infected by chance, or when weakened by overwork, worry, or acute disease. In quiescent cases of a more advanced stage the general health and hence the local conditions are usually much improved. In certain far advanced cases with ex- tensive softening and persistent fever, a voyage in equable waters— say upon the Pacific, as from San Francisco to Japan and return by way of Hawaii — has been known to mitigate symptoms'and to prolong life. Sometimes such patients can even benefit by excursions into cooler regions, as to Alaska, Iceland, or Spitzbergen. When patients are to be sent to a special land climate, as from Europe to Colorado, or from America to the Alps, or from either to Australia or South Africa, the sea trip may be made a special feature of the cure ; and, similarly, sea trips may be directed to well-chosen objective points, in- vigorative or protective as may be, where the patients may remain for a time before coming home. Counter indications. — Grave lesions of the heart and blood-vessels interdict any ocean trip ; nor should a longer voyage than the week between Europe and America be permitted in the great majority of cases of far advanced tuberculosis, chronic gastro-intestinal disorders, chole- lithiasis, or chronic diseases of the abdominal viscera. Gouty patients may suffer more severely at sea than on land ; neuralgias are often aggravated ; hemorrhoids may become troublesome. Among other conditions necessi- tating caution, or even the prohibition of a voyage, are a marked tendency to haemoptysis, great general weakness, special liability to seasickness or loss of appetite, epilepsy, maniacal tendencies, periodic insanity, suicidal inclina- tions, marine photophobia, and marine insomnia. Solomon Solis Colien. SEBORRHCEA. — Definition. — For the purposes of this article seborrheea may be defined as a functional dis- order of the glands of the skin, characterized by the pro- duction of an excessive amount of fatty material, normal or abnormal in quality, which manifests itself upon the skin as an oily coating, scales, or crusts. History. — The investigations of recent years have done much to determine the true limitations of this dis- ease. Many points, however, remain unsettled, espe- cially in the domain of etiology and pathology, and it is very probable that the future will render possible a defi- nition of greater precision. The process of evolution of the present-day conception of seborrheea is of interest, as showing the gradual differentiation of species from genus. ' The old Greek and Roman observers— Hippoc- rates, Galen, Celsus, Actuarus, and others— recognized the occurrence of falling of the hair; and by the Greeks the expression irirvpiaaiq, pityriasis (that which is win- nowed, i.e., husks, bran), was used to designate a con- dition of the skin and scalp characterized by the for- mation of scales. This was, in the light of our present knowledge, a very broad application of the term, and probably included, among other morbid states, that dis- ease which we know to-day as seborrlum sicca. The name porrigo was given by the Roman writers, notably Celsus, to pathological conditions of the skin attended by scale formation. It was not, however, until the lat- ter part of the eighteenth century that any suggestion of a differentiation of the general class into specific types was made. Plenck, in 1783, described, quite concisely, a condition very similar to, if not identical with, our seborrhw sicca, and stated that the flaky material was to be regarded as a product of the sebaceous glands of the scalp. His view was not generally accepted by his con- temporaries; the term pityriasis continued to *be used in its comprehensive sense— including practically all squa- mous conditions— until well into the nineteenth century. A few investigators, however, seemed to have followed Plenck in the endeavor toward scientific differentiation. The terms Teigne (or Tinea) amiantacee and T. furfuraeee were applied by Mahon to conditions apparently sebor- rheic. Brett noted the occurrence of oily, scaling lesions upon parts of the body not covered with hair, and coined therefore the expression acne sebacee. The terms secretions morbides des follicules sebacees and flux sebace were used by Rayer in 1827, referring to mor- bid conditions of the sebaceous glands. In Hebra's time REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. Seborrhoea. Seborrhoea. and during the period immediately preceding him, der- matologists were still seeking a better separation of sebor- rhoea from the general class pityriasis, with varying suc- cess. Puchs, in 1840, it is said by Sabouraud, was the first to make use of the term seborrhoea. In more recent years, largely as a result of the work of Unna, those cases formerly regarded as seborrhoea, in which an inflammatory process is present, have been set apart in a class by themselves, under the caption eczema seborrhoieum (which see). Unna himself would draw the line more closely, and would include in the class mentioned practically all types of seborrhcea sicca, since, he believes, inflammation is always present in these. His conception is not unanimously accepted in its entirety by dermatologists. The exclusion of the inflammatory process from seborrheas, and their limitation strictly to functional disturbance, has greatly narrowed the field ; it has imposed an added burden upon the diagnostician : that of determining where functional disorder ceases and organic change begins. Symptomatology. — The classification of seborrhceic conditions clinically is not a settled one, especially as re- gards minor distinctions. For practical purposes, how- ever, two general types may be considered : seborrhoea oleosa and seborrhoea sicca. These have been variously designated by authors ; the former has been called stear- rhcea, steatorrhma, seborrliagia, sebaceous flux, acne sebacee fluente, hyperidrosis oleosa (Unna); the latter, pityriasis simplex, seborrhoea furfuraeea seupsoriasiformis, erythema capitis, acne sebacee seohe, eczema seborrhoieum squamosum, (Unna). Seborrhoea oleosa may affect both the hairy and the non- hairy parts of the body. It most commonly appears upon the face and scalp, but it may occur on the chest, back, pubes, genitals, and in the axillae. Obviously, in these latter regions it is seen much less frequently by the physician. When the scalp is involved the hairs are covered with an excess of oil ; they are greasy to the touch; tend to mat together into bunches and strands, and in the uncleanly an offensive, rancid odor may be pres- ent. The scalp itself is generally pallid and cool, and is covered with an oily secretion; when the head is bald this gives the skin a shining, though sometimes muddy appearance. Itching is either absent or of a very mild grade; redness is not commonly present; when these are found to any pronounced degree, it is a fair presump- tion that some irritating factor has entered in to modify the classical type. Neglected cases of this type of sebor- Thoea affecting the scalp generally result in a severe alo- pecia. Upon the face, the parts most involved are the nose {especially thealae nasi), the adjacent parts of the cheeks, the chin, and the forehead. The unusual flux of fatty material gives the face a yellowish, oily appearance ; in addition, a dirty, "smudgy" quality is imparted, owing to the ready adherence of dust and soot particles to the greasy surface. The orifices of the sebaceous glands are large, and are generally filled with a visible, yellowish- white plug. Upon pressure these are discharged upon the skin surface, and oily material exudes from the patu- lous ducts. Some redness may be present, more fre- quently about the alae nasi, but usually the skin is cool and without inflammatory changes. Should these ap- pear the condition can no longer be considered a simple seborrhoea. The domain of seborrhoea sicca is disputed territory. Inasmuch as the questions concern largely the matter of classification, the writer will seek to give that sympto- matology which has been accepted by the majority of dermatologists of the present time. The most frequent type of seborrhoea sicca is seen upon the scalp in the condition commonly known as "dan- druff. " It is here characterized by the formation of fine, pulverant or flaky, and slightly oily scales, grayish- or yellowish- white in color, about and between the hairs. They may be scanty, requiring the use of the nail or a blunt toothpick to demonstrate their presence ; or so abundant, especially upon the vertex and the regions im- mediately anterior thereto, as constantly to shower the patient's shoulders with a flaky dust. Underneath the scales the scalp is pale, dry, and non -inflammatory. The hair appears to be deprived of its natural unguent, loses its lustre, becomes dry, thin, and atrophic, and eventu- ally falls, the resulting alopecia being generally syin- metrical and permanent. The subjective symptoms in mild cases are absent or very slight ; if the scale forma- tion is profuse there may be considerable itching and burning. This leads frequently to a modification of the clinical picture. The constant trauma from scratching in neurotic individuals who have neglected treatment soon induces a dermatitis, which, combined with already existing conditions, produces a type approaching eczema seborrhoieum. In these cases excoriated areas may be seen, usually small, upon which are formed yellowish, moist, friable crusts, distinctly greasy; beneath, a red- dened, slightly exuding base may be found. The crusts, when removed, are quickly renewed ; subjective itching and burning are quite pronounced. Conditions similar to the characteristic seborrhoea sicca of the scalp are not uncommonly found in the eyebrows, eyelashes, mustache, and beard ; it is more rarely seen in the pubic region. Upon non-hairy portions of the face, e.g., the nose and adjacent parts of the cheeks, a contin- uous desquamation sometimes occurs ; the scale is thin , grayish-white, and greasy ; the skin is usually reddened and hypersemic. The relation of this condition to rosacea is very close. However, upon non-hairy portions of the body the crusting forms are more commonly seen. These are best exemplified along the edge of the scalp, abo»t the ears, upon the nose and adjacent folds, between the shoulders, and in the sternal region. The secre tion over the diseased areas forms crusts, which are yellowish, greasy, friable, and often rather bulky ; the skin beneath is pale or, more often, reddened slightly. If a crust be removed with care, prolongations may be seen extending from the under surface into the gaping sebaceous openings. The crusting forms frequently exhibit a serpiginous border, slightly raised, and somewhat more reddened than the central portions. The periphery, too, bears a bulkier crust, while the centre is either clearing or entirely free from scales. This form is best seen upon the chest, the back, and along the frontal hair border. The terms " flower-leaf " and " petaloid " have been used to desig- nate the type. Seborrhoea may occur upon the genitalia. In the male it is manifested by the formation of quantities of white, cheese-like, glandular secretion, and epithelial debris about the posterior portion of the glans, the corona glandis, and the sulcus behind the latter. In the normal and cleanly individual functional hyperactivity of the glands of these parts is practically without symptoms ; but in the filthy, from want of proper ablutions, and in the phimosed, from the anatomical conditions present, the retention of this secretion leads to various reflex ner- vous disturbances, and very frequently sets up a severe local inflammation. In the female, the secretion forms about the clitoris and the folds of the labia minora. If the individual be cleanly, there are no symptoms; in ne- glected young children and in the uncleanly, a vulvo- vaginitis may develop. A form of crusting seborrhoea sicca occurring in infants is called crusta lactea, " milk crust. " Imperfect removal of the vernix caseosa from the head is the probable cause, though it is stated that the condition may arise after perfect cleansing of the new-born child. The crusts may cover nearly all the scalp or be confined to a small area. As to physical character, they are variable : they may be bulky or thin, moist or dry, tough or friable, and present a color dependent upon the complexion and surroundings of the child. Generally they are greasy and rather ad- herent ; the surface beneath is reddened and moist. It is probable that these cases should be regarded as instances of eczema seborrhoieum. since they present the picture of a dermatitis planted upon a seborrhceic base. Kaposi, under the caption ichthyosis sebacea, has de- scribed a condition of the skin in infants which he re- 87 Seborrhea. Seborrhoea. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. gards as a true seborrhoea, arising from the continued excessive production of the vernix caseosa. The skin is reddened, tense, and covered throughout with a greasy- coating ; it fissures readily, especially about the mouth, and subsequent inability to nurse leads to inanition and early death. That this is a seborrhcea is extremely doubtful. The same author has mentioned a seborrhcea occurring in the aged and marasmic, pityriasis tabescen- tium, characterized by scaling of the trunk and extensor surfaces of the limbs. The pathological position of this is also in doubt. Neuman was the first to call attention to a peculiar seborrhceic condition found in the aged, which he desig- nated as verruca senilis. Unna gives it the name of ver- ruca seborrheica. By the French it is known as acne sebacee concrete. The lesions are found upon the face, including all parts, the neck, the arms and hands, the trunk, and lower limbs. They vary in size and outline, may be single or grouped, are yellowish-brown or darker in color, sometimes nearly black. The skin between may he atrophic. Upon close inspection each lesion is seen to be raised, slightly verrucous, rough to the feel, and cov- ered with a scale or crust, which is adherent and beneath which a reddened papillomatous surface is found. There maybe slight itching. Hyde has called this a pre-epi- theliomatous seborrhcea, an expression which is peculiarly apt, for if malignancy has not yet shown itself among the lesions it may be expected to appear in time ; and the condition is almost invariably an accompaniment of can- cer of the skin in those of advanced years. Etiology and Pathology. — Seborrhea oleosa may oc- cur at any age, but is most frequently seen in the second and third decades of life. The puberal epoch, so espe- cially characterized by rapid growth of hair and hyper- activity of the sebaceous glands, often develops this form of seborrhoea. The disease occurs more commonly in women than in men, and brunettes are more susceptible than blondes. A tendency to oiliness of the skin is decidedly more marked in some races than in others; that shining, greasy condition of the negro's skin, which in him may he considered physiological, would be, in the white man, an evidence of abnormal glandular activity. Among certain classes of European immigrants to this country, seborrhcea oleosa is common. Various predis- posing causes may be mentioned: disordered blood states, derangements of the digestive and assimilative functions, chronic constipation, convalescence from acute diseases, improper hygiene and habits of life, excesses in eating and in the use of alcohol ; and, in women, men- strual disorders. Factors having a purely local action are sometimes efficient, as continuous exposure of a part to heat, local pressure tending to produce congestion, rosacea, etc. Elliott reports having observed its devel- opment on the site of a recently healed erysipelas. Uncomplicated seborrhcea oleosa may be regarded as a functional disease, and pathological changes in the skin glands are not to be expected, though microscopic foci of inflammation are doubtless often present. It must not be forgotten, however, that the presence of an oily film upon the skin favors the entrapment of micro-organisms, and thereby predisposes to the implantation of an inflam- matory process upon the pre-existing functional disturb- ance. Thus one may see a seborrhoea attended or followed by acne, folliculitis, furunculosis, sycosis, eczema, etc. Unna has ably championed the view that the coil glands participate in the formation of fatty secretion. He there - fore proposes the term hyperidrosis oleosa as more accu- rately expressive of the true condition present when an excess of oil is poured out upon the skin. Seborrhcm sicca, both the scaling and the crusting forms, may occur at any time of life. Blondes are more often attacked than brunettes ; men exhibit the disease rather more frequently than women, the probable reason being that with the former the pilary growth upon the body is more pronounced, their daily toilet of the hair is less thorough, and their headdress less hygienic. The same predisposing factors hold as for seborrhcea oleosa. Espe- cially to be mentioned are convalescence from acute dis- 88 ease, syphilis, and the local influence of pressure and lack of ventilation about the head. A seborrhceic element is quite commonly found in the syphilides of the scalp and face, and one may see most typical forms of crustingi seborrhcea sicca and eczema seborrhoicum beneath the stiff, unventilated head-dress of the nun. The pathology of seborrhcea sicca is much in dispute. While there may be no clinical evidence of inflammatory action, the latter may be demonstrable microscopically. The view commonly held as to the origin of the scales is that they result from an imperfect metamorphosis of the epithelium lining the sebaceous glands into sebum, which abnormal product is extruded upon the skin, mixed with fat and horny epithelial debris. According to this con- ception, the essential process is found in a pathologic physiology of the glandular epithelium. The most radical dissenters from this theory are Unna and Sabouraud, both of whom, for their originality of work, are entitled to great credit. The former's teach- ings may be summarized as follows : All forms of seborrhcea sicca should be classed as eczema seborrlioicum ; the coil glands are the source of fat in the scales (since seborrhceic catarrh with greasy scales may occur in the palm of the hand and sole of the foot), which fact he has repeatedly demonstrated by osmic-acid stain- ing; the sebaceous glands and their secretion are normal, or the glands are filled with fatty cells and show no un- degenerated epithelium ; exit from the glands is blocked by an excess of horny cells in the follicles ; the flow of fat from the coil glands is chemotactic ; a definite tendency to acanthosis and parakeratosis is present within and without the hair follicle; the morococcus is practically always found, the bottle bacillus frequently ; when the scalp is concerned, the openings of the hair follicles are choked and dilated with horny cells extending to the ducts of the sebaceous glands; there is a tendency, from pressure effect, to early separation of the papillary hairs, with failure of their new formation, hence the alopecia; after permanent fall of the hair, the sebaceous glands hypertrophy, and often form true sebaceous cysts. Sabouraud's pathology, which is a still greater depart- ure, is as follows : There are two forms of seborrhcea: a moist type, sebor- rhcea oleosa, and a cystic type, acne comedo ; of the first, the elementary lesion is a fatty sebaceous plug ; this plug contains an enormous number of very small bacilli, which are constantly present in pure culture and are character- istic; the comedo is the cystic transformation of the seba- ceous plug, the change occurring in relatively few of them; eventually the comedo becomes infected with ordi- nary cocci of the skin, among them the "gray-cultured" coccus, producing various types of acne; baldness is a microbacillar seborrhoea, each follicle from which the hair has fallen having been invaded by colonies of the bacilli; this bacillus grows on acid media, forming red colonies, and stains with Gram's method; the different forms of pityriasis are separated and distinct conditions from seborrhoea, but may be superimposed upon the latter ; their lesion is the scale, an exfoliation of horny epider- mis; this scale is produced by a special micro-organism the bottle bacillus. A description of the various organisms mentioned by these two observers would require greater space than the limits of this article will permit. It will suffice to state that dermatologists and pathologists are not at all agreed that these micro-organisms are specific for the condition* named, or even that they exist as distinct varieties. Diagnosis.— The recognition of seborrhcea oleosa pre- sents no difficulties. Seborrhcm sicca must be differen- tiated from the following : Eczema. In a pure eczema there is always evidence of inflammation, either in acute weeping or chronic infiltra- tion; crusts are non-greasy, of coagulated serum; scales are dry, free from oil (unless treated with ointments,) and rather adherent; burning and itching are always present. However, the dividing line between seborrhcm sicca and eczema seborrhoicum is often very difficult to draw, since the former frequently merges into the latter. REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. Seborrlioea. Seborrhea. The feature of greatest importance in the differentiation is the absence in the one and the presence in the other of visible evidence of inflammation and of itching, though these may be present only in a slight degree. Psoriasis. Psoriasis of the scalp is seldom seen unac- companied by patches elsewhere. In mild cases affect- ing the scalp the lesions are generally small, more or less isolated, covered by an adherent, silvery, non-greasy scale, beneath which an easily bleeding surface is found ; between the lesions the scalp is normal or a true sebor- rhea may exist. If the psoriasis is severe, parts of the head may be covered with a thick, dry, non-oily crust, through which the hair is growing vigorously; other regions of the scalp are clear. Alopecia, as a rule, does not result in a pure psoriasis, even though the scalp be severely and chronically affected. Psoriasis is not com- monly seen upon the face, and very rarely about the nose, a frequent site of seborrhcea. Upon the body it is easily distinguished if it be remembered that the outlines of the lesions are more distinct, the scales copious, lus- trous, and non-greasy, and the surface beneath reddened and easily torn. Lupus Erythematosus. The seborrliaa congestim of Hebra was probably lupus erytliematosus. The differen- tiation is made by considering that in this disease the site of lesion is generally the face; the outlines are dis- tinct and elevated; the scale is very adherent, non- greasy ; the skin beneath is reddened to a marked degree ; scar tissue may be present in the vicinity; and close inspection X>f the lesion will reveal atrophic changes in progress, for in lupus erythematosus structural alterations occur which lead to cicatrices on healing. Ichthyosis. This disease is generally present from birth. The scale is universal, dry, non-oily; the skin reddened, dry, and tends to fissure readily along the lines of flexure and cleavage. Frequently, but not always, malnutrition is present, sometimes to a marked degree, especially in the young. Syphilis. Seborrhcea often complicates well-defined syphilis, but cases are not common in which an absolute exclusion of the latter disease must be made. When such is the case, recourse must be had to the past history of the individual as to exposure, initial lesion, adenopathy, exanthem, mucous patches, headaches, alopecia, etc., and to careful searching for the relics of an ancient syphilis upon the skin and mucous membranes. The crusting lesions of syphilis about the face and scalp are more defined in outline, and generally present the copper hue about their borders, which is so characteristic in specific disease. It must not be forgotten that any ulcerating lesions upon the scalp may produce enlargement of the nearest lymph nodes, a knowledge of which fact will help in the avoidance of mistakes in diagnosis. Tinea Tricophytina. Here the decisive proof is the demonstration of the fungus. Upon the scalp the lesions present a dull gray, non-greasy, adherent crust, through which broken, fragile hairs project. Treatment. — In the management of seborrhea due regard must be had for the patient's general condition. Much can be accomplished by a careful regulation of the diet, attention to personal hygiene, and such general measures as shall restore and maintain a normal physiol- ogy of the various bodily functions. Especial attention should be directed to the digestive tract. Seborrhcea oleosa may be treated locally with mildly stimulating applications, the object being to restore the normal function by purging the glands. Such applica- tions, however, should not be continuously used. The medicaments of most value are sulphur, resorein, tinct- ure of benzoin, and white precipitate. The first three may be used in pomades or in weak alcoholic lotion ; the last in an ointment only. Toaccomplish results the ap- plication should be strong enough to produce a reaction with scaling, after which a milder treatment should be followed. The use of astringents is of doubtful value ; if resorted to it should be certain that the secretions from the glands are thinner than normal. Since the a-ray has a selective action on the more highly differentiated cells of the skin, causing atrophy, it has been suggested that conditions due to glandular hyperactivity were amenable, theoretically, to 0-ray ther- ' apy. Seborrhtm oleosa would therefore be included in the , category. The consideration is purely theoretical; the writer knows of no published reports of cases so treated. Seborrhcea of the genitals disappears with cleanliness. In the scalp seborrhea sicca requires rather elaborate and persistent treatment. In severe cases crusts and scales must first be removed by maceration with an oil, followed by a shampoo ; in mild cases by the shampoo alone. The official tinctura saponis viridis or Sarg's fluid soap will serve well as material for the shampoo. When the scalp is thoroughly cleansed a stimulating pomade should be applied. For this precipitated sulphur, resor- ein, and the red sulphuret of mercury are most efficient, either singly or combined, the ointment base used being soft. 3$ Sulph. pracip 1.00 Hydrarg. sulph. rubr 05 Ung. petrol, alb 30.00 M. Sig. : Pomade for scalp. In severe cases this should be rubbed into the scalp every day for a week or more ; afterward less often. Patients generally object strongly to the greasy condition of the hair following the frequent use of an ointment. It is ad- vantageous in such cases to prescribe a lotion, which may be applied six days in the week, the shampoo and pomade being used on the remaining day. Sulphur, being insoluble in water and alcohol, cannot be made an ingredient of the lotion ; resorein and bichloride, com- bined with other stimulants, as tincture of cantharides, are the most efficient compounds available. 1$ Hydrarg. bichlOr 10 Tr. cantharid 30.00 Spts. vini. rect 80.00 Aq. rosarum ad 200.00 M. Sig. : Lotion for scalp. To this, if indicated, a small proportion of oil may be added; the amount should rarely exceed 10 gm. in 200. Resorein is credited with producing a slight change in the color of blond hair. For such the bichloride lotion is preferable. For the crusting forms of seborrhcea of the face and body, sulphur and resorein are the remedies par excel- lence. Crusts should be removed by softening with oil and the careful use of water in which some borax has been dissolved. A pomade containing the above-men- tioned drugs in suitable proportions may then be applied. Care must be taken in treating these cases that an acute dermatitis be not awakened. Should this happen, sooth- ing measures must be used until the skin will permit fur- ther treatment of the original condition. The crusta lactea in infants may be avoided in the vast majority of casesiy a gentle but thorough cleansing of the child after brrth. Should characteristic crusts de- velop later, a mild course of treatment following the lines mentioned above will bring about a cure. The verruca senilis, or the pre-epitheliomatous sebor- rhcea of advancing years, requires careful watching for epitheliomatous developments. ]?or the purpose of keep - ing the lesions soft, a mild pomade may be used. Cau- terization is not advisable. If an extensive removal of the lesions be contemplated, resource must be had to z-ray therapy. The two forms of Kaposi — ichthyosis sebacea and pityriasis tabescentium — require careful attention to the general nutrition of the patient, and the use of such ointments locally as will keep the skin soft and pliable. Prognosis. — The outlook for sebwrlum oleosa is de- pendent largely upon the strictness with which the pa- tient carries out general instructions. Seborrhcea sicca of the scalp requires faithful treatment ; if it is neglected, re- 89 Secretin. Secretion. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. currence is probable; alopecia is generally permanent. The seborrhceas of the body are more easily controlled. The same is true of crusta lactea in infants. Pre-epitheli- omatous seborrhea is not so unfavorable since the intro- duction of the a-ray as a therapeutic measure in skin diseases. In Kaposi's forms the prognosis is undoubtedly grave. Stelwagon calls attention to the frequent presence of hypertrichosis in those suffering from seborrhoea of the face. It should be remembered that the prolonged use of greasy applications is certain to add to the hair growth already present. Ernest Lewis McEwen. SECRETIN. — It has long been known that the intro- duction of acid into the intestine (duodenum) provokes a flow of pancreatic juice. Popielski and Wertheimer and Lepage demonstrated that this result may follow even after the exclusion of nervous impulses from without these organs. The secretion has therefore been attrib- uted to the effects of a peripheral reflex brought about independently of central nervous influences. Since this flow of pancreatic juice will apparently follow even after inhibition of all nervous elements by atropine, it has been ascribed to a chemical stimulation of the pancreatic gland cells. The name secretin has been given by Bayliss and Starling to the chemical substance, as yet not isolated and identified, which is the direct stimulant to the gland. Wertheimer does not believe, however, that secretin acts independently of any nervous relations; and like Pfluger he points out the difficulty in obtaining complete isola- tion of an organ from nervous elements. The specific substance is obtained by extracting the mucous coat of the jejunum with 0.4 per cent. HC1. A very small por- tion of such an extract injected into the circulation suf- fices to call forth a copious flow of pancreatic juice. The active agent is not the HCl.since this alone does not provoke secretion when introduced directly into the blood current. Secretin is not present as such in the intestine, but is formed from a precursor, prosecretin, by the action of the acid. The transformation of prosecretin into se- cretin can also be accomplished by the action of boiling water or salt solution. The acid secretin solutions can be boiled and neutralized without undergoing a diminu- tion in activity. The active substance thus does not be- have like an enzyme. It is not precipitated by alcohol or ether ; and presumably further investigation will de- monstrate it to be a definite chemical individual of rela- tively low molecular weight. Camus has found that secretin may be formed in all animals examined by him, viz., the dog, cat, rabbit, guinea-pig, pig, pigeon, and frog. Lafayette B. Mendel References. Bayliss and Starling : Centralblatt fur Physiologic, 1901, xv., p. 682 — Proceedings of the Royal Society, London, 1902, lxix., d. 352.— Jour- nal of Physiology, 1902, xxvili., p. 325. Camus and Gley : Comptes rendus de la Socie'te' de Biologle, 1902, llv pp. 242, 465. Wertheimer: Ibid., 1902. liv., pp. 472, 474. Pfluger : Archiv f tir die gesammte Physiologle, 1902, xc, p. 32. Camus: Comptes rendus de la SocMte' de Biologle, 1902, liv., pp. 442 513 Herzen and Radzikowski : JIM., 1902, liv., p. 507. Fleig : Centralblatt f. Physiologic 1903, xvi., p. 681. SECRETION, PHYSIOLOGY OF.-By secretions we mean the products of the activity of gland cells. Usually these products are liquid or semi-liquid in char- acter. In recent years a distinction has been made be- tween internal and external secretions. By the latter term we designate a secretion that is discharged upon a free epithelial surface that communicates with the ex- terior. Such, for example, are the secretions of the glands of the skin or of the mucous membrane of the alimentary or respiratory tract. The name internal se- cretion is used to designate those secretions that are dis- charged into the blood or the lymph. The term is used especially in connection with the so-called ductless glands, such as the thyroids or the adrenal bodies, but it happens that in some cases a gland possessing a duct may form an DO internal as well as an external secretion. A good exam- ple of this combination of functions is found in the case of the pancreas. The external secretion of the pancreas, the pancreatic juice, is emptied through its duct into the duodenum, while its internal secretion, of an unknown character chemically, is discharged into the blood. As will be described later, the two secretions in this case are formed in all probability by two different kinds of gland cells. It will be convenient to consider these two kinds of secretion separately. External Secretions. The composition of the external secretions varies greatly, but in general we may say that they consist of water, inorganic salts, and certain organic constituents. The organic elements in the secretions have aroused the greatest interest since they may be characteristic of the secretion. They are found in some instances (for exam- ple, the urea of the urine) preformed in the blood, and the function of the gland cell is a selective one, picking out this particular constituent and discharging it into the lumen of the gland. In other cases the organic element is not present in the blood or lymph, and must therefore be formed within the substance of the gland cell. In both cases there is a general agreement, speaking broadly, that the gland cells take an active part in the secretion and that the production or elimination of the organic products involves the expenditure of energy on the part of these cells. We picture this energy as 'dependent upon the chemical changes, the metabolism within the gland protoplasm, and naturally the character of these changes may vary greatly. General theories of secretion have concerned themselves chiefly with the physiological mechanisms by which the secretion is excited, and the means by which the inorganic constituents of the secre- tion are produced, whether in response to purely physi- cal forces such as filtration, osmosis, and diffusion, or by means of unknown activities of the living proto- plasm. The general nature of the theories proposed and the modifications suggested for the different secretions can be given best by describing the physiology of the most important secretions. Secretion of the Sauvart Glands.— Under the designation salivary glands we must include all the glands whose ducts open into the mouth cavity and whose secretions contribute to the formation of the sa- liva. Ordinarily, however, the term is applied to the three large pairs of glands, the parotid, the submaxillary, and the sublingual. The duct of the parotid, duct of Stenson, opens opposite the second molar tooth of the upper jaw; the duct of the submaxillary, duct of Whar- ton, opens at the side of the fraenum of the tongue ; the duct or rather ducts of the sublingual, open into the floor of the mouth and are usually known as the ducts of Rivinus; although in some animals, and sometimes it is said in man, one of these ducts, the duct of Bartholin, may be especially conspicuous and runs parallel with the duct of Wharton. The portion of this gland which empties into the mouth by the duct of Bartholin is desig- nated by Ranvier by the separate name of the retro- lingual gland. Histologically these large glands show certain differences in structure. The secreting cells of the alveoli may belong either to the albuminous or to the mucous type. In the former the cells are relatively small and densely granular in appearance, so that in fresh sections of the living gland the outlines of the individual cells cannot be distinguished readily. In the mucous type the secreting cells are larger and much clearer. In the living condition they present a homo- geneous ground-glass appearance, but on appropriate treatment display a few large granules much less opaque than those in the albuminous cells. These two types of cells may be found in the same gland or even in the same alveolus: but, speaking generally, the parotid in man contains chiefly albuminous cells, and the submax- illary and especially the sublingual, chiefly mucous cells. This difference in histological structure is associated with REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Secretin. Secretion. a chemical difference in the secretion. The saliva from the submaxillar}' and the sublingual contains mucin and is thick and stringy, while the parotid saliva, although it contains some albumin, is free from mucin and is thin and limpid. Each of these glands receives a double nerve supply one set of fibres coming from the cervical, Fig. 416t. -A Section Through the Human Sublingual Gland. (Bohm- Davidoil.) sympathetic and the other directly from the cranial nerves. The parotid receives its cranial nerve fibres by a very indirect path. In the dog in which their course has been worked out experimentally the fibres arise from the brain in the glossopharyngeal, pass into the tym- panic branch of this nerve, also known as the nerve of Jaeobson, and thence to the small superficial petrosal through which they reach the otic ganglion. In branches from this ganglion they pass to the auriculo-temporal branch of the inferior maxillary, and thence by several small branches to the gland. This path is supposed to involve two nerve units, the first which may be desig- nated as the cranial or preganglionic neurone ending in the otic ganglion ; the second, the sympathetic or post- ganglionic neurone, arising in the otic ganglion and end- ing in contact with the gland cells. The cranial fibres for the submaxillary and sublingual are found in the chorda tympani nerve. They arise with this nerve from the facial and pass with it to join the lingual branch of the inferior maxillary. After running in the lingual for a short distance the secretory (and vaso-dilator) fibres branch off in several small strands which pass toward the hilus of each gland following the course of the ducts. This path also involves two nerve units. The cranial or preganglionic neurone ends in nerve cells of the sympa- thetic type, which, in the case of the submaxillary, are found in its hilus or along the duct, while in the sublin- gual they form a collection, conspicuous enough to be seen with the eye, and located in the angle made by the strands of fibres as they leave the lingual nerve. This collection of nerve cells was formerly designated as the submaxillary ganglion, but since Langley has shown by the use of the nicotine method that they are intercalated in the course of the nerve path to the sublingual gland, it is more appropriately named the sublingual ganglion. These sympathetic cells constitute the second or post- ganglionic neurone which ends in the gland cells. The sympathetic nerve supply to the three glands is in gen- eral the same. The fibres emerge from the spinal cord in the upper thoracic nerves, pass over to the sympathetic chain in the corresponding rami communicantes, ascend in the neck in the cervical sympathetic, and terminate, so far as the first neurone is concerned, in the cells of the superior cervical ganglion. From this ganglion sympa- thetic neurones pass but in strands that form a plexus in the coats of the arteries supplying the glands. These fibres are usually stimulated while in the cervical sympa- thetic or by applying the electrodes to the superior cer- vical ganglion. Composition of the Saliva. — The saliva of the mouth consists, or may consist, of the mixed secretions from the large salivary glands together with the secretions of the small unnamed glands of the buccal mucous membrane. In addition to accidental constituents, such as epithelial cells, it contains mucin, a small proportion of albumin, an amylolytic enzyme known as ptyalin, and inorganic salts. The saliva of each gland maybe collected sepa- rately by inserting a cannula into its duct. By this means it can be shown that the secretion of each gland has its own characteristics, the parotid saliva, for instance, being free from mucin, while the sublingual and the submax- illary saliva have varying proportions of this substance, but contain little or none of the ptyalin. Experiments by Pawlow indicate that the secretion of each gland may be excited differently under normal conditions. He found that in dogs the submaxillary secretion is readily excited by sapid bodies in the mouth, or by the sight or smell of food, while the flow of parotid saliva is especially marked when dry substances are placed in the mouth. Secretory Nerves. — The discovery that these glands are supplied by secretory nerve fibres, we owe to Ludwig. In 1851 he found that stimulation of the lingual nerve causes a flow of saliva from the submaxillary gland. Bernard showed that the fibres in question belong to the chorda tympani, and discovered in addition that during the stimulation of this nerve there is a greater flow of blood through the gland. We now know that the chorda tympani conveys both secretory and vaso-dilator fibres to the submaxillary and sublingual. The natural sugges- tion that the increased secretion on stimulation of this nerve is due to the greater blood flow has been disproved by a series of experiments. It has been found, for in- stance, that after administration of atropine stimulation of the nerve is followed by a vascular dilatation without any secretion, and, on the other hand, that injection of quinine ma} r cause a dilatation of the vessels without a secretion, which, however, is readily obtained if the nerve is stimulated. Evidently the glands possess true secre- tory fibres capable of starting and maintaining a secretion from the gland cells. It was found, subsequent^, that stimulation of the cervical sympathetic nerve gives a small flow of saliva which is characterized by its large amount of solids and by the fact that during the stimu- lation the blood flow through the gland is diminished in consequence of the simultaneous stimulation of vaso- constrictor fibres. Corresponding to these facts, Heiden- hain found for the parotid gland that stimulation of the cranial nerve fibres in the nerve of Jaeobson, gives an abundant secretion of thin saliva, while stimulation of the cervical sympathetic gives little, or, in the case of the dog, no secretion. In the latter case, however, it was discovered that stimulation of the sympathetic fibres has an effect on the gland, although no visible secretion is produced. Sections of the gland, for instance, after FIG. 4165.— A Section Through the Human Parotid Gland. (BOhm- Davidofl.) such a stimulation show that the lumina of the alveoli and the ducts are distended with secretion, and if the cranial fibres are stimulated simultaneously with or sub- sequently to that of the sympathetic fibres, the secretion 91 Secretion. Secretion. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. that forms instead of being thin and watery is thick, and on chemical examination shows a much larger percentage of solid matter. We are justified therefore in stating for all the salivary glands that each receives a double nerve supply, and that the sympathetic saliva, as it is called, is much smaller in amount and much richer in solids than that obtained by stimulation of the cranial fibres, the chorda or tympanic saliva. The physiological signifi- cance of this double supply of secretory fibres is not un- derstood at present. The evidence that we have shows that reflex stimulation of these glands takes place through the cranial fibres alone, and, on the other hand, that in- m Wl Fig. 4166.— Parotid Gland of the Rabbit in a Fresh State, showing Portions ot the Secreting Tubules, i, In a resting condition; B, after secretion caused by pilocarpine ; C, after stronger secretion, pilocarpine and stimulation of the sympathetic ; D, after long-continued stimulation of the sympathetic. (Langley.) jury to or experimental section of the cranial fibres is followed by a loss of function of the glands. In what way the sympathetic nerve supply participates in their functional activity is not explained. Relation of the Secretion to the Strength of the Stimulus. — As in the case of the neuromuscular apparatus, it is found that the extent of the secretion varies with the in- tensity of the stimulus, or, in other words, we can get a series of submaximal secretions by varying the stimula- tion. The experiments upon this relationship have been made in connection with the cranial nerve supply. Ac- cording to Heidenhain, the quantity of water and the percentage amount of inorganic salts increase as the stim- ulus increases up to a certain maximum, while the per- centage amount of organic substances shows a more vari- able relation. If the gland is unfatigued at the beginning of the experiment the proportion of organic substances increases rapidly as the stimulus grows, but the maximum reached is not maintained if the stimulation is continued. On the contrary, continued stimulation may give a saliva containing less and less of the organic constituents, al- though the water and salts may continue to show a max- imal proportion. The absence of parallelism under these conditions led Heidenhain to conclude that the condi- tions controlling the secretion of the organic material are different from those governing the formation of the water and salts. This conclusion is expressed in his theory of salivary secretion which will be mentioned briefly below. Normal Mechanism of the Secretion of Saliva. — The se- cretion of saliva may be excited reflexly by stimulation of various sensory nerves, particularly those of the mouth. The action in this case is, of course, reflex, and, as said above, the efferent path to the glauds is through the cranial fibres, for if these fibres are cut a reflex secre- tion cannot be obtained. Although this reflex secretion may be obtained by electrical stimulation of the sensory 92 nerves of the mouth, it may be produced most easily and abundantly by the chemical stimulation caused by sapid substances. We may assume therefore that under nor- mal conditions the sapid substances of the food stimulate the sensory endings of the lingual and glossopharyngeal nerves in the mouth cavity and start afferent impulses to the medulla which reflexly stimulate the motor cells giv- ing origin to the cranial secretory fibres. We have abun- dant evidence that the same motor cells may be stimu- lated reflexly through other sensory paths. The idea of food, for instance, or the sight or smell of agreeable food to a hungry person may make the mouth water, and, on the other hand, gastric irritation may give the same reaction, as is shown by the disagreeable (low of saliva that accompanies an attack of nausea. Under normal conditions the large salivary glands in man secrete only when reflexly stimulated; the secretion, in other words, is not continuous but is dependent on stimulation through the nerves. Since, however, the mouth cavity is al- ways more or less moist even in sleep, it is prob- able that there is a continuous secretion from the smaller unnamed glands embedded in the buccal mucous membrane. Histological Changes in the Gland during Secre- tion. — Much experimental work has been done upon the changes in microscopic appearance of the gland cells during secretion. This work was of great importance in proving that the gland cells take an active part in the secretion. Sec- tions made of* the fresh or of the hardened gland show that after prolonged secretion the gland cells are smaller than in the resting state. More- over, in the gland at rest granules are formed within the cells, and during active secretion these granules slowly disappear. The most interesting observations arc those made by Langley on sec- tions from the living gland. He finds that in the parotid 'gland the cells during the resting stage are densely granular throughout. As the gland is made to secrete the granules begin to disap- pear first from the outer border, and after pro- longed stimulation they may disappear almost entirely, the few that are left being clustered round the margin of the cells bordering on the lumen. In the mucous glands the granules are larger and clearer and much less numerous. They swell and disappear on the ad- dition of water, and it may be assumed that they rep- resent the mucin found in the secretion, or a preparatory material which during secretion is dissolved by the water formed, and is thus discharged from the cell. Action of Atropin. Pilocarpin, and JSicotin on the Sali- vary Glands. — The three alkaloids named exert an inter- esting and typical action on the secretion of the salivary glands. Atropin injected into the circulation or into the gland directly through its duct will destroy its power of secretion. The gland cannot be made to secrete either by director by reflex stimulation. Inasmuch as the gland refuses to secrete when the stimulus is applied directly to the hilus, we may conclude that the action of the drug is either upon the gland cells themselves or upon the ending of the nerve fibres in their cells. Since stimula- tion of the sympathetic nerve supply may produce the usual flow of sympathetic saliva, we may'conclude that the gland cells are still functional, and tliat the effect of the atropin is to paralyze the endings of the cranial secre- tory fibres. Pilocarpin or muscarm has a directly oppo- site effect. In proper doses each sets up a continuous secretion of saliva, and this effect may be prolonged by repeated injections of the drugs. It is assumed that these alkaloids stimulate chemically the endings of the nerve fibres in the gland cells. Atropin and pilocarpin exhibit toward these and many other glands the same antagonis- tic action that they exert upon the inhibitory nerve fibres of tiie heart. The action of nicotin has been studied chiefly by Langley. He finds that injection of this alka- loid causes first a slight stimulating effect followed soon by a temporary paralysis of both the cranial and the sym- REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. Secretion. Secretion. pathetic fibres. After the stage of paralysis is reached it is found that stimulation of the second or post-gan- glionic neurone of each path will give the customary secretion. It would seem from this result that the nico- tin paralyzes the connection between the first or pre- ganglionic and the second or postganglionic neurone. This action of nicotin takes place for other kinds of nerve fibres in which the path involves the union of a cerebro- spinal with a sympathetic neurone. Paralytic Secretion.— After section of their cranial nerve supply, chorda tympani and nerve of Jacobson, the sali- vary glands give a slow continuous secretion which may keep up for several weeks. Eventually, however, the glands undergo atrophy and lose their normal structure in spite of the fact that they still possess a connection with the central nervous system by way of the sym- pathetic nerve fibres. This paralytic secretion occurs only when the cranial secretory fibres are destroyed, in- jury to the sympathetic supply alone has no such effect. The cause of the continuous secretion is not evident. Langley is inclined to the view that it is dependent upon a continuous excitation of the nerve cells within the gland, the post-ganglionic neurone. Section of the chorda, or the nerve of Jacobson, would be followed in a few days by a total degeneration of the pre-ganglionic neurone, but the second or post-ganglionic neurone would probably retain its structure and irritability for some time. Langley's view is not very satisfactory, inasmuch as it throws no light on the nature and origin of the supposed excitation. Theory of Salivary Secretion. — Some of the constituents of saliva, e.g., mucin and ptyalin, do not occur in the blood and must therefore be formed within the gland cells as a result of a special metabolism. The histologi- cal changes in the gland cells during secretion corroborate this conclusion. Heidenhain has suggested the hypothe- sis that the metabolism giving rise to the organic products in the secretion is under the control of a special variety of the secretory fibres for which he proposed the name of trophic fibres. A second set of fibres which he desig- nated as secretory fibres proper control the formation of the water and salts. The action of the trophic fibres is readily understood. Like the motor fibres to the mus- cles, their impulses set up katabolic changes which result in the formation of mucin, ptyalin, and the peculiar pro- teid found in the secretion. The action of the fibres sup- posed to control the production of the water and salts is more difficult to explain. When the gland is at rest there is no flow of water through the gland cells from the blood and lymph. In this condition therefore the protoplasm of the cells is impermeable to the water and salts. When the secretory fibres are stimulated the flow begins promptly, and we might suppose that the action of the impulses conveyed by the nerve fibres causes a physical alteration in the gland cells, in consequence of which they become permeable to the water and salts. Since, however, under continuous stimulation of the secretory fibres the hydrostatic pressure in the occluded ducts may exceed the pressure in the capillaries and arteries, it is evident that mere filtration through the cells will not ex- plain the flow of water. There must be some substance within the gland cells possessing a high osmotic pressure and capable therefore, if we may use the expression, of at- tracting tlie water. Heidenhain makes such an hypothesis. He assumes that normally the gland cell at rest contains water under tension in consequence of the osmotic press- ure of its substance, but that this water cannot escape into the ducts in consequence of the impermeability of the limiting layer of the cells bordering upon the lumen of the alveolus. The effect of the secretory impulses is to alter the structure of this limiting layer so as to make it permeable, and the stream of water and salts will con- tinue as long as this permeability is maintained. It would seem necessary for the completeness of the hypoth- esis to assume that the border of the cells resting upon the basement membrane is constantly permeable to the water, but only in one direction, that is, from the lymph toward the interior of the cells. Langley is inclined to believe that the hypothesis of two kinds of nerve fibres is unnecessary, and that it is preferable to assume that one and the same set of fibres may cause the katabolic changes leading to the formation of the organic products and at the same time control the flow of water and salts. On the histological side it may be said that there is no indication of two kinds of fibres or two sets of nerve endings in the gland. The Secretion op the Panckeas. — The pancreas has much the same general histological structure as the sali- vary glands. The alveoli contain granular cells belong- ing to the albuminous type, but characterized in the rest- ing stage by a clear non-granular zone on the basal side. The histological changes during secretion are especially distinct and resemble those described for the parolid gland. During active secretion the size of the cells is diminished, the granules disappear from the basal side, and the non-granular zone extends farther toward the inner margin of the cells. In the resting stage, on the contrary, granules are again formed within the cells, and the non-granular zone is reduced in size. Physiological evidence indicates that the granules within the cells con- sist of a preparatory material from which the several enzymes of the secretion are formed, and they are there- fore designated usually as zymogen granules. In addi- tion to this type of cell, which is undoubtedly responsi- ble for the formation of the pancreatic secretion, the pancreas contains an entirely different kind of cell found in groups that are known as the islands of Langerhans. These cells seem to be connected with the production of the internal secretion of the pancreas, and will be de- scribed more fully under that head. The chief duct of the pancreas in man, the duct of Wirsung, opens into the duodenum together with the common bile duct at a dis- tance of 8-10 cm. below the pyloric orifice. The nerves of the pancreas are derived from the solar plexus, but physiological experiments indicate that ultimately the gland receives nerve fibres from two sources, the vagus and the sympathetic nerves. Composition of the Secretion. — The pancreatic secretion is an alkaline liquid, which in some animals is clear and limpid and in others thick and glairy. From a physio- logical standpoint the most important constituents are the enzymes of which three or four have been described. These are trypsin, a proteid-splitting enzyme ; lipase, a fat-splitting enzyme; amylopsin, a starch-splitting en- zyme, and in some animals chymosin, a milk-curdling enzyme. The strong alkaline reaction of the secretion is' due to sodium carbonate. A number of organic sub- stances may also be present in small amounts, such as albumin, peptones, leucin, tyrosin, xanthin, soaps, and fats. Secretory Nerve Fibres. — Direct observations on animals like the dog, in which the processes of digestion are not continuous, have shown that the flow of pancreatic juice is intermittent and related to the periods of digestion. This fact would indicate that its secretion, like that of the salivary glands, is caused by reflex stimulation. Di- rect experimental attempts to prove the existence of secretory fibres were unsuccessful until the beautiful work done by Pawlow and his pupils. These workers found that stimulation of the peripheral end of the cut vagus or splanchnic under proper conditions causes a secretion of the juice. The latent period between the stimulation and the beginning of the flow from the pan- creatic duct is quite long, from three to five minutes, and has been explained on the hypothesis that the nerves stimulated carry secretory as well as inhibitory fibres, both of which would be stimulated by the method used. The existence of inhibitory fibres is made probable also by the fact that when a secretion is in progress stimula- tion of the peripheral end of the cut vagus may bring the flow to a standstill. If the existence of both secretory and inhibitory fibres to the gland be accepted, recent work, which will be described in the following paragraph, makes it probable that these nerve fibres have only a regulating control over the secretion. Even when all the extensive nerve connections are severed the gland may secrete in 93 Secretion. Secretion. REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. connection with the digestive processes. Unlike the sal- ivary gland the secretory fibres from the central nervous system are not apparently essential to secretion, but reg- ulate it after the manner that the extrinsic nerves regu- late the movements of the stomach or the heart. Normal Mechanism of the Pancreatic Secretion.— After Pawlow's discovery of the secretory fibres to the pan- creas the natural supposition was that the mechanism of I. 3. h. s. 6. 7. s. At y \ ho / /" / \ \ / / / \ \ \ 32 / / \ \ \ \ / / / / \ i U ■ / \ \ x ■' 1 \ \ \ \ ib / / / \ ; / / / \ a // / \ \ \ N // \ 1 N --"- N N ■; "* **'-^. 4 / y .Milk. OkeacL Fig. 4167.— Three Curves showing the Secretion of Pancreatic Juice upon a Diet (1) of 690 c.c. of milk ; (2) of 250 gm. of bread ; (3) of 100 gm. of meat. The divisions along the abscissa represent hours after the beginning of the meal ; the figures along the ordinate represent the quantity of the secre- tion in cubic centimetres. (Walter.) secretion is analogous to that of the salivary glands, that is, some peripheral sensory stimulus in the intestines stim- ulates these secretory fibres reflexly. It was supposed, in fact, that the acid chyme ejected from the stomach acts upon the sensory fibres of the mucous membrane of the duodenum and sets going the normal reflex that causes the pancreatic secretion. This view was founded upon the fact, demonstrated by several observers, that acids applied to the duodenal membrane will start the pancre- atic secretion. Popielski, however, asserts that the same reaction is obtained when the vagi and sympathetic are cut on both sides, so that if the reaction is effected by a nervous reflex this reflex does not involve the central nervous system. More recently an entirely new light has been thrown upon the subject by some most interesting investigations made by Bayliss and Starling. Tliese au- thors find in the first place that acid (0.4 per cent. HC1) placed in the duodenum or jejunum will cause a secre- tion of the pancreatic juice when the loop of the intestine used (jejunum) has all of its nervous connections severed. Moreover, if the mucous membrane from the duodenum or jejunum is scraped off and treated with the acid, the solution so obtained when injected into a vein causes an active secretion by the pancreas, although the acid alone or the extract of the mucous membrane without t reat- ment by acid is ineffective. The authors apparently have proved that normally the acid from the stomach or the acid formed (lactic) during digestion acts upon the mu- cous membrane and produces a substance which Un- designate as secretin. The secretin is absorbed, carried to the pancreas, and either stimulates the pancreatic j cells directly, or, possibly, acts upon the intrinsic nerves of the gland. Secretin is not, an enzyme; boiling or the action of absolute alcohol does not destroy it. Accord- ing to this new and interesting discovery the secreting nerves play no necessary part in the normal mechanism of pancreatic secretion, and if this turns out to be the case we shall have to attrib- ute to them merely a regulat- ing influence upon the secre- tion. The flow of pancreatic juice caused by secretin is characterized by the fact that it does not contain an active trypsin, but recent experi- ments go to indicate that any normal flow of pancreatic j uice possesses the same pecu- liarity. It would seem that in the normal secretion the tryp- sin is contained in the form of zymogen or pro-enzyme, and that it becomes converted to the active enzyme when it comes in contact with the in- testinal mucous membrane. , The conversion is made by the peculiar enzyme found in the intestinal secretion by Sche- powalnikow and to which Pawlow has given the name of enterokinase (see heading of Intestinal Secretion). The normal sequence of events, then, in the secretion of pan- creatic juice is, first, the for- mation of secretin by the action of the acid of the gas- tric juice on the mucous mem- brane of the small intestine ;- second, the action of this se-j cretin, after absorption into the blood, upon the pancreatic cells ; third, the conversion of the zymogen of the secretion ' into the active enzyme by the enterokinase of thesuccus en-, tericus. This last act may be necessary only for the i trypsin. The curve of secretion of the pancreatic juice has been determined with care in the case of dogs. According to experiments made upon animals with a pancreatic fistula, the secretion begins shortly after the introduction of food into the stomach, and increases in volume to a maximum, which is rcachedbetween the first and the third hours. The curve then falls again more slowly to the base Hue. although there may be a second smaller rise from the fifth to the tenth hour. The general character of the curve is shown by the accompanying figure (Fig. 4167). Relation of the Composition oftlie Secretion to tlie Char- acter of the Food. — The work from Pawlow's laboratory indicates that the composition of the secretion varies \ somewhat with the character of the food, and that the variation has the appearance of a beneficial adaptation. I That is, proteid foods cause in some way the secretion of a juice rich in proteolytic enzyme, and oily foods a secretion with an increased amount of lipase. This state- i ment needs further experimental confirmation. If cor- ' rect it shows a kind of biological reaction between the food and the secretion which it, is difficult to explain sat- isfactorily. Pawlow maintains that similar specific stin;- I uli in the food influence or control the composition of the gastric and salivary secretions. We have here a relation- ship which, when more fully investigated, may prove to be of much practical importance in dietetics. -5Keof 94 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Secretion. Secretion. Secretion op the Gastric Glands. — The accepted method of obtaining the gastric secretion dates from the famous work of Beaumont. His use of an accidental fistula in the case of St. Martin indicated at once that similar fistulas might be established upon animals for experimental purposes. Operations of this kind were performed first by Basson and by Blondiot in 1842, and were used subsequently by many investigators. At first, metal cannulas were placed in the fistulous openings to facilitate the collection of the secretion, but modern sur- gical technique has enabled experimenters to avoid this clumsy and often injurious device by converting a por- tion of the reflected mucous membrane into a tube open- ing on the surface of the skin. With a fistula of this character the stomach contents cannot escape to the ex- terior and yet can be drawn off at any time by the inser- tion of the catheter. The difficulty in sucli experiments is that the secretion becomes contaminated with the food, and its analysis is therefore difficult or impossible. Hei- denhain obviated this difficulty and opened the way to successful investigation of the secretion by his device of cutting off a portion of the stomach, especially the f undic end, so as to form an isolated sac opening to the exterior. The remainder of the stomach was closed off by sutures so as to maintain the continuity of the alimentary canal. In such animals the food does not enter the isolated f undic sac, but nevertheless starts a secretion in it which may be obtained through its fistulous opening entirely free from mixture with the food. By this means the quan- tity, rate of flow, and composition of the secretion may be studied satisfactorily under various conditions. This operation was subsequently improved by Pawlow, who introduced a variation by means of which the nervous supply, as well as the vascular supply of the isolated sac, was maintained intact. The character of this oper- ation is shown in the accompanying diagram (Fig. 4168). Pawlow devised also a secondary operation which in his hands has led to important results. In this operation the oesophagus was divided in the throat, and both upper and lower ends were brought to the surface of the skin to form permanent fistulas. After such an operation the food that the animal chewed and swallowed did not enter the stomach, but escaped to the exterior through the upper oesophageal fistula. By this means the effect of the act of eating upon the gastric secretion was deter- mined. It was found that a fictitious meal of this char- acter causes an abundant secretion of gastric juice in spite of the fact that none of the food enters the stomach, and this fact in turn led to the discovery of secretory nerves to the gastric glands. Composition of the Secretion. — In addition to the mucus formed by the columnar epithelium on the surface of the mucous membrane, the secretion as collected contains water, inorganic salts, hydrochloric acid, pepsin, rennin, and usually a trace of peptones. The amount of the hy- ; drochloric acid may be as great as 0.56 per cent, in the dog, but in the human gastric juice is usually given as ' 0.2-0.3 per cent. The secretion does not decompose easily — in fact, specimens may be kept for long periods without undergoing any putrefaction and without losing their digestive action. Evidently the secretion has marked antiseptic properties which are doubtless due to the free hydrochloric acid it contains. There has been considerable discussion as to the composition of the secre- tion from different parts of the stomach. The marked difference in histological structure between the glands of the cardiac and those of the pyloric end would suggest that their respective secretions' might vary in character, i According to most observers, the pyloric mucous mem- : brane, when isolated from the rest of the stomach, gives a secretion that is alkaline in reaction but contains some pepsin and rennin. The hydrochloric acid, therefore, must be formed in the glands of the cardiac end. As far as is known, the glands of the pyloric end add nothing that is characteristic or essential to the secretion. Nerwus Control of the Secretion.— Much experimental work has been done to ascertain whether or not the flow of gastric juice is under the control of secretory nerves. The earlier experiments were inconclusive and need not be recalled, since in recent years Pawlow has obtained positive evidence of secretory nerve fibres. With the aid of his pupils and co-workers he has demonstrated the following facts: When a dog is given a fictitious meal by means of the oesophageal fistulas described above, there is a flow, often an abundant flow, of gastric juice, although no food gets into the stomach. If, however, the two vagi are cut previously, the fictitious meal does not cause a secretion. Evidently, therefore, the act of eating must occasion a reflex secretion of gastric juice, and the efferent paths in this reflex must pass to the stomach by way of the vagi. B}' the same means it was shown that the sight or smell of food will cause a reflex secretion in a hungry animal. After these preliminary experiments had indicated the existence of secretory fibres positive proof of their existence was obtained by direct stimulation of the peripheral end of a cut vagus. Under proper conditions of stimulation a flow of gastric juice can be obtained in this way, although the latent period of the secretion is unusually long, from four to ten minutes. Normal Mechanism of the Gastric Secretion. — Beaumont and later observers held that mechanical irritation of the gastric mucous membrane is capable of provoking a secre- tion, and that the food therefore acts in part, especially in the beginning of digestion, as a mechanical stimulus. Pawlow, however, states positively that this belief is erroneous, and that mechanical stimuli are entirely inef- fective. Heidenhain gave convincing evidence that the normal stimulus is a chemical one derived from the food, and this fact was afterward confirmed by the more de- tailed and satisfactory experiments made by Pawlow, who has given us a nearly complete account of the means by which the flow of gastric juice is started and main- tained during digestion. According to this author, the first flow of the gastric juice is caused reflexly by the sight or smell of food, or more especially by the act of eating, and constitutes what he calls the psychical secre- tion. This term is used because the sensory nerves stim- ulated are the gustatory, olfactory, or optic nerves, and the reflex is accompanied by the conscious and agreeable sensations associated with eating. The term seems to imply also that the reflex arc involves the cerebral cor- tex, and is thence continued to the secretory fibres in the Fig. 4168.— Figure from Pawlow to show the Operation of Forming an Isolated t'undie Sac (S) and its Opening at the Abdominal Wall, A, A ; V, cavity of the stomach. vagus. The secretion produced in this way appears promptly, and under favorable conditions may be abun- dant in quantity. In one experiment in which the ficti- tious feeding was continued for several hours, it is stated that about 700 c.c. of pure gastric juice were obtained. A further flow of the secretion is caused by the action of Secretion. Secretion. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. the food upon the stomach itself. According to the ex- periments reported, there are some foods which contain substances capable of acting chemically upon the mucous membrane and arousing a flow of gastric juice, probably by a nervous reflex; such foods are the meats, meat extracts, milk, gelatin, and water. Other foods, such as bread or white of eggs, do not possess this power. If introduced into the stomach through a fistula without the animal's knowledge so as not to arouse a psychical £sg 6 a ~ 01 1.3 S • TOlVk. Meal. 5buad. 600.ee. 100 it. 100 jfr- 10 I b h i o.n) 0.AJ0 0.43J 0.3W O.lii o.m O.ikO 0.192 0.141* o.o% MAI P a lb \k a 10 / 6 A i : \ ■ \ ■ \ : \ ., ; \ ; \ ; ; \ ; \ *, \ ; \ i \ "T 1 \ j x v r~ v ^ / y .oaii- 1 * 3 A S ( 7 I 9 10 11 It (Xuildy. OJidtitiue poum. II 1 1 1 SS=BS^=S Fig. 4169.— Curve showing the Flow and Composition of the Gastric Secretion in a Dog Fed upon a Mixed Diet. (Khigine.) secretion, they remain undigested. If, however, these foods are digested for a time they then acquire the power of stimulating a flow of gastric juice. Under the normal conditions of eating, such foods would first start a psy- chical secretion, and after they had begun to be digested by this secretion the flow would be maintained by the chemical stimuli developed from them in the process of digestion. These chemical stimuli upon which the flow of gastric juice depends mainly, which are present al- ready formed in some foods and are developed in others by digestion, Pawlow groups under the general designa- tion of secretogogues. He has not, been able so far to ascertain their chemical nature. The dietetic value of meat extracts seems to lie largely in the fact that they contain much of these secretogogues and thereby favor the digestion of other foods. Curve of Secretion and its Variation with the Character of the Food.— la its general features the curve of gastric secretion, so far as its quantity is concerned, resembles that of the pancreatic juice. The flow begins promptly after the act of eating, increases somewhat rapidly to a maximum, which in dogs fed on a mixed diet is reached at about the second hour, and then falls slowly toward zero as the stomach is emptied. The composition of the secre- tion during this period varies somewhat, the first flow being relatively weak in the two important constituents hydrochloric acid and pepsin. The illustration (Fig. 4169) gives an example of the way in which the secre- tion varies in a dog fed upon a mixed diet. Pawlow states that in a general way the quantity of secretion varies with the amount of food, a relation which is easily understood when we remember that the food itself sup- plies the stimulus for the secretion. The same worker has given some proof that the composition of the secre- tion is related to the composition of the food, and that it may be possible, when the relation has been more completely investigated, so to modify the food as to in- crease one or the other of its important constituents. Histological Changes during Secretion. — The gastric glands in the cardiac end of the stomach contain two types of cells, the chief cells, and the cover or border cells. The latter vary in number in different regions, but in most cases form a discontinuous layer along the length of the tubes, and in the pyloric region they are lacking entirely. Histological and experimental evidence indicates 'that the chief cells are responsible for the secre- tion of the enzymes of the juice. During the resting stage these cells are filled with zymogen granules which disappear to a greater or less extent during active diges- tion. In accordance with this histological fact it is found that aqueous extracts of the mucous membrane in the resting stage may contain but little active pepsin or ren- nin, but that if this extract or the mucous membrane be- fore extraction is treated with certain reagents such as dilute acids, an abundant yield of enzyme is obtained. In normal secretion the presence of the hydrochloric acid is sufficient in itself to convert the zymogen to enzyme, so that in the normal gastric juice no zymogen or pro- ferment is found. With regard to the enzymes, there- , fore, we may assume that, as in the other digestive j glands, they are formed within the cells as a result of their metabolism, that they are stored during rest as zymogen : granules, and that, during or immediately subsequent to their secretion, the zymogen is changed to the active,' enzyme. With regard to the secretion of the acid preva- lent theories are much less satisfactory. Origin of the Hydrochloric Acid. — It is not known defi- nitely which of the two cells found in the gastric tubules gives rise to the hydrochloric acid. The fact that the py- loric glands do not contain border cells and that their secretion is alkaline instead of acid suggests the view that these border cells are concerned in the formation of the acid, hence they are sometimes designated as oxyntic cells. No direct proof, however, has been furnished to show that these cells have anything to do with the produc- tion of the hydrochloric acid. On the chemical side also t the mode of origin of the acid is still obscure. In general, \ it is believed that the hydrochloric acid must arise ulti- I mately from the chlorides, especially the sodium chloride of the blood, and, according to one hypothesis, the acid is formed by a reaction between the chlorides and the phos- phates of the blood according to the formula NaH a P0 4 -fNaCl = Na 2 HP04 + HCl, the reaction being effected in some way through the activity of the gland cells. Another hypothesis is that the chlorides are decomposed by the mass action of the CO a formed in the metabolism of the gland tissue, and that the reaction is facilitated and the liberated base combined by au acid nucleo- proteid known to exist in the gastric mucous membrane. Neither hypothesis helps us much to understand why the hydrochloric acid is formed only in this particular tissue and not elsewhere in the body. Acid indicators, such as acid fuchsin or a solution of ferric acetate and potas- sium ferrooyanide, show that the free acid is present only on the surface of the membrane and not within the sub- stance of either the border cells or the chief cells. In 96 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Secretion. Secretion. view of this result it lias been supposed that the acid is not actually formed within the cells, but in the secretion after its discharge; or if formed within the cells, it is eliminated as rapidly as it is formed, so that there is no accumulation within the cell itself as in the case of the zymogen. In accordance with this l^pothesis it has been suggested that the hydrochloric acid is actually formed outside the mucous membrane from ,the chlorides of the stomach contents. This view assumes that the mucous membrane is impermeable to the chlorine ions, but permeable to the hydrogen ions, and that the latter passing through the mucous membrane from the blood, combine with the chlorine of the dissociated chlorides of the stomach contents. The hypothesis can scarcely be 1 considered a probable one, since an abundant secretion of 'acid juice may be obtained by stimulation of the vagus nerve or in the isolated fundic sac when the stom- ach is entirely empty. Nor does the hypothesis help us to understand at all the part taken by the secretory cells. We must, in fact, confine ourselves at present to the gen- eral statement that the chlorine of the hydrochloric acid is derived ultimately from the chlorides of the blood. Secretion op the Small Intestines — the Succtrs Entehicus. — Although there is no question that the cells of the small intestine form enzymes which take an ac- tive part in the digestion of the food, there is some doubt whether these substances are actually discharged in a liquid secretion upon the inner surface of the intestine. Some mucus is formed and secreted by the epithelial cells, particularly those of the large intestine, but this mucus is not known to have any digestive action of a chemical nature. To ascertain whether a liquid secretion other than the mucus is formed in the small intestine, recourse has been had usually to experiments with a Thiry-Vella fistula. In this operation a loop of the intestines is iso- lated and the two ends are sutured into the skin of the abdominal wall, giving thus a portion of the intestine whose contents can be examined without possibility of contamination from the food or from the secretions of the pancreas or liver. Experiments of this kind agree in showing that an alkaline liquid forms in the loops, and indeed more abundantly in loops from the lower than in those from the upper portions of the small intestines. [From experiments of this kind Pregl estimates that as much as three litres may be secreted in twenty-four hours from the entire intestine. The estimate must be received, however, with caution. Most observers agree / sthat this liquid has no digestive action on proteids, but ; 'may contain an amylolytic enzyme. Extracts of the walls of the small intestine, on the contrary, give solu- | tions that contain four or possibly five important en- zymes. There are, first, the essential group of sugar- splitting enzymes capable of converting the disaccharides to the monosaccharides, namely, maltase which converts ' maltose to dextrose, invertase which converts cane sugar to dextrose and levulose, and possibly lactase which con- verts lactose to dextrose and galactose. In addition it has been shown recently by Cohnheim that these ex- tracts contain a powerful proteid-splitting enzyme, erep- sin, which splits the peptones and proteoses into simpler - crystallizable substances— leucin, tyrosin, arginin, etc. Whether or not these enzymes are actually discharged into the intestines as a liquid secretion, they must be regarded as formed within the substance of the intesti- nal epithelial cells by a metabolism peculiar to these cells and analogous to the process of secretion in other glands. We must place the intestinal epithelium among the important digestive glands. Quite recently also the intestinal secretion from the upper part of the small in- testine at least has been found to contain an enzyme-like substance, enterokinase, which, while it has no digestive action of its own, seems to be able to increase greatly the activity of the enzymes of the pancreatic juice. This effect is particularly marked in regard to the impor- tant proteolytic enzyme trypsin. Apparently this latter enzyme is secreted entirely in the form of a zymogen i and can have no effect upon the food until it is "acti- ■ vated " by the enterokinase. We owe this important ad- Vol. VII.— 7 dition to our knowledge of intestinal digestion to Schepo- walnikow, working under Pawlow's directions. This work has since been confirmed by several observers, and it is claimed by Delezenne that the enterokinase can be obtained also from leucocytes and lymph glands, and in the small intestine is found most abundantly in the mu- cous membrane overlying the Peyer's patches. Secretion op Bile. — As in the case of the other ' glands many efforts have been made to demonstrate the existence of secretory fibres to the liver controlling the flow of bile. The secretion of bile is continuous, the metabolic processes in the liver cells leading to its forma- tion and discharge are in progress at all times, although the velocity of the flow varies. Experimentally the f velocity of the secretion may be increased or decreased,! but the variations are so strictly parallel to the concomi- tant changes in the circulation that a causal connection) between the two is rendered most probable. Stimula- tion of the spinal cord or the splanchnic nerves dimin- ishes the flow of bile in proportion as it causes a diminu- tion in the blood supply. Section of the splanehnics, on the other hand, which causes a dilatation in the blood- vessels of the abdominal viscera, is said to increase the secretion of bile. The usual view, therefore, is that the velocity of secretion of the bile varies with the volume of the blood flow through the liver. This belief seems to imply that the secretory activity of the liver cells as re- gards the bile is controlled by the composition of the blood. With regard to the excretory products of the bile, the bile pigments, lecithin, and cholesterin, one can un- derstand that the greater the quantity of blood flow through the organ the greater will be the excretion. It is more difficult to comprehend the relationship between the blood flow and the increased secretion of water, salts, and bile acids, and no satisfactory hypothesis has been sug- gested to explain the relationship. Curve of the Secretion of Bile. — Owing to the ease with which a biliary fistula may be established in man as well as in the lower animals, our knowledge of the daily curve /o 8 6 2 30' 30' 30' 30' 30' 30' 30' 30' 30' 30' 30' 30' 30' 30' JO' / % _ 1 / / N. s i i / \ i 1 \ 8 : ■■ \ : i ---. ■-^ ! \ i 8 £ ■I / / / \ , ... — i i \ /' \ \ s / / 1 ■ \ / •• / / --. > «^_ Fig. 4170.— Curves showing the Rapidity of Secretion of Bile into the Duodenum on (1) a diet of milk, upper curve ; (2) a diet of meat, middle curve ; (3) a diet of bread, lower curve. The divisions on the abscissa represent intervals of thirty minutes ; the figures on the ordinates the volume of the secretion in cubic centimetres. (Bruno.) of the secretion is fairly accurate. In man the quantity secreted varies between 500 and 800 c.c. in the course of a day, or taking into account the weight of the individ- ual the secretion averages from 8 to 16 c.c. per day for 97 Secretion. Secretion. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. each kilogram of body weight. Although the secretion is continuous, it shows a marked acceleration during the period of digestion between the third and the fifth hours after the ingestion of food, that is, during the period of maximal activity in the small intestine. Upon the gen- eral theory of secretion stated above, this increase in the secretion should be related to the greater blood flow through the liver at this period, and the altered composi- tion of the blood following absorption of the digested products. Absorption, which is at its maximum during this time, must lead to a greatly increased metabolism in the liver cells, and the augmented secretion of bile is one expression of this increased activity. Although the secre- tion is continuous, the actual injection of bile into the duodenum through the common bile duct is intermittent in those animals which possess a gall bladder. The se- cretion in such animals is stored in the gall bladder, and by means of a definite nervous mechanism this reservoir is emptied at intervals during the course of digestion. Ejection of Bile into the Duodenum. — The mechanism by which the bile is emptied into the intestine does not seem to have been investigated by recent observers. Ac- cording to Bruno, the ejection through the common bile duct is dependent upon the passage of chyme from the stomach into the intestine, and varies with the character • of the food. As long as the stomach is empty no bile is found in the duodenum. The chyme therefore must con- tain substances which, acting upon the sensory surface of the duodenum, lead to a reflex contraction of the gall bladder. Bruno thinks that the digested proteids (pro- teoses and peptones) and fats furnish the efficient stimuli. Acids, alkalies, and starches were found to be ineffective. There seem to be no data regarding the frequency of occurrence of these contractions during digestion or the action of stimuli other than the chyme. The nervous mechanism involved in this reflex has been studied by Doyon and by Oddi. • It appears from their work that the afferent fibres for the reflex run in the vagi, since stimulation of the central end of a cut vagus causes a reflex contraction of the gall bladder together with an inhibition of the sphincter supposed to exist at the ppen- ing of the common bile duct into the duodenum. The efferent path, on the contrary, is through the splanchnics. Stimulation of the peripheral end of a cut splanchnic causes a contraction of the gall bladder and bile ducts. Modification of the Bile in the Gall Bladder. — It is well known that the so-called mucin of the bile is not formed in the liver cells but from the epithelium of the mucous membrane of the gall bladder and ducts. The chemical nature of the substance seems to vary in different ani- mals ; in some cases it is a gtyco-proteid of the general nature of the mucin of the salivary glands, but in most cases, according to Hammarsten, it is a form of nucleo- proteid. According to Naunyn, the cholesterin of the bile is also added through the epithelium of the bile pas- sages, and does not constitute a portion of the bile as secreted by the liver cells. According to the analyses published, the bile of the gall bladder (bladder bile) con- tains more solids than that of the hepatic ducts (hepatic bile). As this increase affects the constituents known to be furnished by the liver cells, it may be supposed that the bile undergoes a certain amount of concentration while in the bladder in consequence of the absorption of water. Oholagogues. — Numerous experiments have been made upon the effect of various drugs upon the secretion of bile. These experiments have shown that substances which cause a destruction of red corpuscles increase the flow of bile. Direct injection of dissolved haemoglobin into the circulation has the same effect. The increase in the secretion in such cases is said to be transient. The substance that has the most marked and prolonged effect upon the secretion of bile is bile itself. Bile fed to an animal or injected into the circulation accelerates the se- cretion of bile, and the same effect may be obtained by using solutions of the bile acids alone. Since the so- called bile acids have a distinct hsemoly tic action it might be supposed at first that their effect as cholagogues is due to this action on the red corpuscles; but their effect is so much greater than that of other hsemoly tic agents that we must believe that they exert a specific stimulat- ing effect upon the liver cells. Many other substances seem to occasion a slight increase in the flow of bile, but no direct cholagogue of importance has been discovered other than the bile salts themselves. Perhaps an excep- tion will be found to this last statement when further investigations are made upon the physiological action of the secretin formed in the duodenum and jejunum. Attention is called to this substance under the head of pancreatic secretion, and there is some indication that it may play a part as a normal chemical stimulus in the secretion of bile. At the present writing no more pre- cise statement can be made. Secretion op the Kidney. — None of the secretions of the body has been studied with more care than that of the kidney. The especial interest which this secretion pos- sesses for pharmacology and internal medicine as well as for physiology accounts in large part for the attention it has received. In addition it has seemed to offer the best opportunity for testing one of the fundamental ques- tions of secretion, namely, the extent to which the phys- ical processes of filtration, diffusion, and osmosis partici- pate in the act of secretion. Most of the discussion on this point has been along the lines of the two main theories of urinary secretion which have been under discussion now for many years. One theory, proposed first substan- tially by Bowman and afterward supported vigorously in a modified form by Heidenhain, holds that the water and ; salts of the urine are actively secreted by the epithelium \ of the capsule surrounding the glomerulus, while the ,i urea and the other specific organic constituents of the urine are secreted together with some water by the epi- thelium of the convoluted tubules. The other theory we owe to Ludwig. According to him all the constituents of the urine are formed by filtration through the glomer-i ulus. The two layers of epithelium through which this' filtration occurs, the capillary or vascular, and the glom- ; erular epithelium, act simply as a membrane through which the constituents of the urine are filtered off from the blood by the excess of pressure in the blood capil- '. laries. The urine so formed is very dilute, and as it passes along the convoluted tubules it becomes concen- trated by absorption. In both theories a difference of function is supposed between the capsule and the con- voluted tubule. It will be convenient to discuss the functions of these two parts separately. Function of the Glomerulus. — The arrangement of the glomerulus and the capsule presents a structure peculiar to the kidney and suggestive of a special purpose. The glomerulus is a knot of capillary vessels which do not form a plexus but rather a rete "mirabile with a single afferent and a smaller efferent vessel. For physical rea- sons the blood in passing through the glomerulus suffers a diminution in velocity, on account of the sudden in- crease in the width of the stream bed, and yet maintains a high hydrostatic pressure on account of the resistance offered by the narrow efferent vessel and the capillary ; plexus with which it connects. Moreover, there are no lymph spaces round the glomerulus. The epithelium of the blood capillaries is directly adherent to the epithelium of the capsule into which the glomerulus is inserted, so that the cavity of the capillaries Is separated from that of the uriniferous tubules by a double layer of endothe- lial cells. The arrangement suggests a filtering mechan- j ism, and Ludwig's theory supposes that it acts in this way for all of the constituents of the urine. Bowman's theory supposes that only the water and salts are formed here, and Heidenhain, moreover, has given reasons for believing that the water is not formed by mechanical j processes, but by an active secretory process on the part \ of the glomerular epithelium. If attention is paid only to the water and salts it is evident that if Ludwig's the- ory is correct the pressure tending to force them through the epithelium may be expressed by the formula P — p, i in which P represents the pressure in the glomerular capil- laries and p the pressure of the urine in the capsular end i 98 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Secretion. Secretion, of the tubule. According to this theory, the amount of jUrine formed should vary directly with P and inversely 'with p. It is obvious that the factor P may be increased by raising arterial pressure in the renal arteries or by ob- structing the flow in the renal veins, and, according to theory, each change should cause an increased flow of urine. Experiments of this kind have been made. It has been found that raising arterial pressure in the kidney arteries does increase the flow of urine, and vice versa. However, it must be borne in mind that this relationship holds only when the pressure in the glomerular capillaries varies in the same direction as in the renal arteries. All experimental variations which may be safely assumed to raise the pressure in the glomerular capillaries are fol- lowed by a greater flow of urine. The reverse experi- ment, however, of raising P by blocking the venous out- flow fails entirely to support the theory. When the renal veins are compressed the capillary pressure in the glomeruli must be increased, and if the veins are blocked entirely, we may suppose that the capillary pressure is raised to the level of that of the renal arteries. In such experiments, however, the flow of urine is diminished in- stead of being increased, and indeed may be stopped alto- gether when the veins^,re completely blocked. The ad- herents of the Ludwig theory have attempted to explain this unfavorable result by assuming that the swollen interlobular veins press upon and block the uriniferous tubules. According to the antagonistic theory of Heidenhain, blocking the veins suppresses the secretory activity of the glomerular epithelium by depriving it of oxygen and the chance for removal of CO a , and thus producing local asphyxia. The latter explanation seems the sim- pler of the two, and it is very strongly supported by the opposite experiment of clamping the renal artery. !When this is done the blood-flow through the kidney ceases and the secretion of urine also stops as would be expected. But when after a few minutes' closure the artery is undamped the secretion is not restored with the return of the circulation. On the contrary, a long time (as much as an hour or more) may elapse before the secre- tion begins. This fact is quite in harmony with the Heidenhain theory, since complete removal of their blood supply might well result in a long-continued injury to the delicate epithelial cells. On the mechanical theory, however, we should expect the contrary. Injury to the cells should be followed by greater permeability and an increased filtration, as is found to be the case with the production of lymph. These two experiments, blocking the renal -artery and the renal vein, seem at present to discredit the filtration theory and to support the secre- tion theory. If we accept this latter theory it may be asked how it agrees with the experiments mentioned above upon the variations in capillary pressure brought about otherwise than by obstructing the venous outflow. Heidenhain has emphasized the fact that all of these ex- periments involve not only a variation in capillary press- ure, but also in the blood flow, and that it is open to us to suppose that the effect upon the secretion of urine is dependent upon the rate of flow rather than upon the capillary pressure. If we adopt this explanation we are led again to the secretion hypothesis, since mere rate of flow should not influence filtration, but should affect secretion, since it would alter the composition of the blood flowing through the glomeruli and also the supply of oxygen and carbon dioxide. An important fact, which seems at first sight to show the influence of pressure, is that when general arterial pressure falls below a certain point, about 40 mm. of mercury, the secretion of urine ceases altogether. Such a condition may be brought about by surgical shock, by hemorrhage, or by section of the spinal cord in the cervical or thoracic region. But here again the great vascular dilatation causing this fall of pressure is associated with a feeble circulation, and the effect upon the kidney secretion may well be due to this latter factor. In addition to varying the factor P in the formula given above, it is possible also to increase the factor p. Normally the pressure of the urine in the capsule must ' be very low owing to the fact that the secretion drains away as rapidly as it is formed. If the ureter is oc- cluded, however, the pressure of the urine will increase, and the filtration pressure P — p will diminish. When this experiment is performed and the pressure in the ure- ter is measured by a manometer, it is found to rise to 50 or 60 mm. of mercury and then to remain stationary. This fact might be explained by supposing that when p = P the secretion stops on account of the failure of the filtra- ' tion pressure. Little weight, however, can be given to this argument, since it is quite possible that under these conditions the urine may still continue to form, but is re- absorbed under the high tension reached. The experiment , simply serves to show the secretion pressure of the urine, ' and the fact that this pressure rises as high as 50 to 60 mm. mercury, while the fact that the capillary pressure is probably somewhat lower would rather serve as an argu- ment against the filtration theory. Exact figures, how- ever, regarding the capillary pressure in the kidney can- not be obtained, so that the experiment on the whole gives us no satisfactory information regarding the theory- , of secretion. Dreser has used a different argument to prov e that the production of the water involves the performance of work on the part of the epithelial cells. He points out that in some conditions, e.g., after drinking beer, the urine may be very dilute, as shown by the fact that its freezing point may be only 0.18° C. or 0.16° C. below that of pure water, that is, A = —0.18° C. or — 0.16° C. Since blood serum has a = —0.56° C. the difference in concentration between the blood and the urine in such a case of extreme dilution shows an osmotic pressure in favor of the blood equivalent to a = — 0.4° C. Meas- ured in mechanical units this would indicate an osmotic pressure of 49.08 metres of water tending to drive the water from the uriniferous tubules into the blood, where- as the filtration pressure driving the water in the other direction could not at a maximum exceed 2.73 metres of water. Evidently if this argument is just, the elimina- ' tion of the water takes place against a strong opposing os- motic pressure, and the energy necessary for its secretion can be referred only to the activity of the epithelial cells. ' Function of the Convoluted Tubules. — By convoluted tubule is meant that portion of the uriniferous tubule! which extends from the capsule to the straight or col-, 1 lecting tubes. Its epithelium varies, but is distinguished in general from the flat, thin epithelium of the capsule , by a larger amount of granular protoplasm. According to the Ludwig theory, this portion of the tubule func- tions as an absorption membrane and serves thus to con- centrate the dilute urine filtered through the glomerulus. The fact that the urine is often more concentrated than the blood proves that this absorption, if it occurs, is not due to simple hydro-diffusion, and later adherents of this theory have been obliged to abandon the simple physical theory proposed by Ludwig and to suppose that the absorption effected by these cells is a physio- logical process dependent upon their living structure and properties. The Bowman-Heidenhain theory, on the contrary, assumes that these cells are secretory in func- tion and serve for the excretion of the urea, uric acid, etc. With regard to the absorption theory it may be said that positive evidence is lacking, and it is difficult to present briefly the facts that are quoted from time to time in its favor. On the other hand, there is much probable evidence that the secretory hypothesis is nearer to the truth. This evidence may be summarized briefly as follows: 1. It is stated that if the ureters are ligated in birds the urates will be found deposited in the urinif- erous tubules, but never at the capsular end. 2. Hei- denhain has given proof that the convoluted tubules are capable of excreting indigo-carmine after this substance is injected into the blood. His experiment consisted es- sentially in injecting the material into the blood after di- viding the cord so as to reduce the rapiditj r of secretion. After a certain interval the kidney was removed and irrigated with alcohol to precipitate the indigo-carmine in situ in the organ. Microscopic examination showed Secretion. Secretion. REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. that after this treatment the granules of the indigo- carmine are found in the convoluted tubules, but not in the capsules round the glomeruli. 3. Several observers (Van der Stricht, Disse, Trambasti, Gurwitsch) have de- scribed microscopic appearances in the cells lining the tubules indicative of an active secretion. They picture the formation of vesicles in the cells and appearances 1 which indicate the discharge of these vesicles into the cavity of the tubules. 4. Nussbaum made use of the fact that in the frog the glomeruli are supplied by branches of the renal artery, while the rest of the tubes are supplied by the renal portal vein. He stated that if the renal artery is ligated the glomeruli are deprived completely of blood, and that as a result the flow of urine ceases. If under these conditions urea is injected into the circulation it is excreted together with some water, thus proving the secretory activity of the tubules with regard, to urea. Later experiments by Adami and by Beddard have thrown doubt upon this otherwise cru- cial experiment. Adami claims that ligature of the renal arteries does not shut off completely the glomerular cir- culation, while Beddard, although he corroborates Nuss- baum in the point that complete occlusion of the renal arteries suspends entirely the secretion of urine, finds that under these conditions injection of urea into the cir- culation is not followed by a secretion. 5. Dreser has shown that the acidity of the urine is due to an action of ,' the epithelium of the tubules. If an acid indicator, such as acid fuchsin, is injected into the dorsal lymph sac of i a frog, and an hour or so later the kidneys are examined, it will be found that the convoluted tubules are colored 1 red, while the capsular end is colorless, indicating that , the secretion at that point has an alkaline reaction. The . experiment shows that the acid phosphate of the urine . is produced in the convoluted tubules. The simplest explanation is that it is formed by a secretor}' activity of the epithelial cells, although one may adopt the less probable view that the cells produce the acid phosphates by a selective absorption of alkaline salts. On the whole it must be admitted that the weight of evidence is in favor of the Bowman-Heidenhain theory of secretion, and it remains for future investigations to explain more defi- nitely what is meant by the obscure term, secretory activity. Under pathological conditions it has been shown satis- ,' factorily that albumin and sugar which may be present i in the urine are secreted or eliminated at the glomerular end of the tubule. Influence of the Nervous System on the Secretion of Urine. — Although Berkley states that terminal fibrils of the nerves distributed to the kidney may be traced to the epithelial cells of the convoluted tubules, the physiologi- : cal evidence at present is opposed to the existence of secretory nerve fibres. The kidney receives a rich ner- f vous supply by way of the sympathetic, but experiments I indicate that these fibres are vaso-motor in function. Both vaso-constrictor and vaso-dilator fibres have been described, and inasmuch as ihe secretion of urine varies directly with the rapidity and volume of the blood flow, it follows that these vaso-motor fibres must exercise nor- mally an important regulatory infhonce upon the amount of secretion. Action of Diuretic*. — An important side of the theo- ries of secretion of urine is their application to the ac- tion of diuretics. Water, various soluble substances, /such as salts, urea, and dextrose, and certain special ' drugs, such as cail'ein or digitalis, exert a diuretic action on the kidneys. Much experimental work has been done to ascertain whether the action of those substances can be explained mechanically by their influence on the blood flow or the blood pressure in the kidney capillaries, or whether it is necessary to fall back upon a specific stim- ulating effect exerted by them upon the epitheiial cells of the tubules. Adherents of the original Ludwig theory are forced to explain their action by the effect they pro- duce upon the pressure in the kidney capillaries, and indeed it has been shown with reference to the saline diuretics that their effect upon the secretion is in propor- tion to the osmotic pressure they exert. It has been suggested, therefore, that the action of these diuretics lies in the fact that they attract water from the tissues into the blood and thus cause a condition of hydremic plethora. But whether the elimination of this excess of water is due to filtration or to an active secretion by the glomerular epithelium simply revives the discussion that has been presented briefly above. Most observers find that the vascular changes in the kidney, particularly after the administration of caffein and digitalis, do not explain satisfactorily the phenomenon of diuresis, and although it is necessary to admit that the diuretics, or some of them, act in part by the changes which they cause in the circulation in the kidney, those who adopt the Bowman-Heidenhain theory assume usually that these substances exert also a direct stimulating action on the secretory cells. Secretion of the Sebaceous Glands. — Practically nothing is known of the mechanism of secretion of these glands beyond the results furnished by histological ex- amination. It is believed that the secretion is formed not by a liquid discharge from the cells, but by the cast- ing off of the cells themselves. The cells upon the base- ment membrane multiply, and the.daughter cells are dis- placed toward the lumen of the gland. Gradually these latter cells disintegrate, and their debris forms the thick, oily secretion. Secretion of the Sweat Glands. — The secretion of sweat is important, partly because it helps to regu- late the water contents of the body, but mainly because it is an effective means of controlling the body tem- perature. In accordance with these regulative functions we find that the formation of sweat is governed by the central nervous system, by means of which a reflex adap- tation of the process to the needs of the body is made possible. Definite experimental proof of tiie existence of sweat nerves was obtained first by Goltz. He showed that electrical stimulation of the peripheral end of the di- vided sciatic in dogs or cats causes the formation of visi- ble drops of sweat on the balls of the feet. This result has since been confirmed for other parts of the body, and it has been shown that the sweat nerve fibres take much the same course anatomically as the vaso-motor fibres. They take origin in the cord or the medulla, pass over to the sympathetic ganglia where they end round the sym- pathetic nerve cells. Thence their course is continued by a sympathetic neurone, so that they reach their desti- nation probably as non-medullated fibres. Their course for different regions of the body is known with a fair degree of exactness. All the evidence that we have indicates that the sweat glands, like the salivary glands, do not secrete normally except under the influence of these secretory fibres. Ordinary profuse sweating due to a high external temperature must be explained as a reflex act. The high temperature stimulates sensory nerves in the skin, and the impulses thus generated are transmitted to the cord and returned to the sweat glands by the efferent sweat fibres. Attempts have been made to ascertain whether the general activity of these sweat fibres is controlled like that of the vaso-constrictors by a medullary nerve centre. The work done is not conclu- sive, but it seems to indicate that the reflex centres for the system are found in different regions of the brain and cord. In all probability the nuclei of origin of the sweat fibres for each skin area constitute the sweat centre for that region. These nuclei or centres may be stimulated refiexly by incoming impulses from the skin or from the higher nerve centres, or they may be acted upon by changes in the composition of the blood as is shown by the effect of dyspnoea and certain drugs. Atropin and pilocarpin exert their well-known antagonistic influence in the sweat secretion, the latter causing a flow of sweat and the former inhibiting it. As in the case of other glands, the action of these drugs is supposed to be per- ipheral, pilocarpin stimulating the endings of the sweat fibres, and atropin paralyzing them. Nicotin also in proper doses suspends the secretion of sweat, and it is probable that this alkaloid acts upon the connection be- 100 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Secretion. Secretion. tween the spinal or pre-ganglionic neurone and the sym- pathetic or postganglionic neurone. Secretion op the Mammary Glands. — The develop- ment of these glands in connection with the processes of gestation and their functional activity for a variable period after the act of parturition, are the points of great- est physiological interest. It seems evident that the causal connection between the changes in the uterus and in the mammary gland must be established either through the central nervous system or through the blood. During the development of the fa?tus sensory stimuli may be de- veloped in the reproductive organs of the mother which act reflexly upon the mammary gland and stimulate its growth and secretion ; or, on the other hand, the changes in the reproductive organs may result in the formation of an internal secretion, which being discharged into the blood, acts upon the tissue of the gland either directly or through the nervous system. The crucial experiment of destroying the nerve supply of the gland in a pregnant animal has given somewhat unsatisfactory results, but it seems to show that the development and functional activity of the gland proceed as under normal conditions, j although the quantity of milk produced is less. As far as it goes this evidence indicates that the bond of con- nection is furnished by the blood rather than by the nervous system, and we may adopt provisionally the hypothesis of an internal secretion. Assuming that this hypothesis is correct, it still remains possible, of course, that the activity of the gland in lactation may be regu- lated by extrinsic nerves. Many facts speak for this possibility. It is known, for instance, that in women during lactation the flow of milk is influenced by emo- tional conditions, and, on the other hand, histologists have described nerve terminations round the gland cells which look like secretory nerve fibres. The plrysiologi- cal evidence for secretory fibres is, however, quite meagre. Mironow in experiments upon goats has stated that stimulation of sensory nerves causes a diminution in the secretion, but that when the nervous connections of the gland are destroyed this reflex cannot be obtained. Rohrig finds that section of the inferior branch of the external spermatic increases the secretion, while stimula- tion of the same nerve causes a diminished secretion. These experiments might be regarded as proving the existence of inhibitory fibres to the gland, but it is equally, or indeed more probable, that the fibres in ques- tion are vaso-constrictors. The known influence of the central nervous system on the secretion of milk may therefore consist only in the control of the circulation in the gland by means of vasomotor fibres as in the case of the secretion of urine. Internal Secretions. The term internal secretion seems to have been em- ployed first by Claude Bernard, but the essential idea conveyed by it, namely, a secretion discharged into the blood or lymph, had long been entertained in connection with the so-called ductless glands, such as the thyroid. About 1889 the term and the idea implied by it were emphasized by Brown-Sequard in connection with work upon testicular extracts. This author suggested that not only the glands but all tissues may have internal secre- tions of greater or less importance in the general nutri- tion of the body. This extension of the original concep- tion was-not justified by subsequent experiments and to-day we must limit the use of the term to the distinctly glandular bodies. Experience has shown, however, that not only the ductless glands hut some at least of the typical glands with well-defined ducts may produce in- ternal secretions. There is no a priori way of deter- mining whether or not a glandular structure produces an internal secretion. The matter must be decided by ex- periment and observation. Internal Secretion of the Thyroid Tissues. — Under the term thyroid tissue we may include the thyroid bodies, the accessory thyroids which have a similar, indeed iden- tical structure, and the parathyroids whose structure is peculiar, but whose function seems to be closely related to that of the thyroids. The history of the discovery of the functions of the thyroids, so far as we know them, fe most interesting and illustrates admirably how experi- mental physiology may co-operate with experimental and clinical work in medicine and surgery. The early work indicated that removal of the thyroids is followed quickly by marked symptoms of disturbed metabolism, cachexia, muscular tremors and spasms which soon end in death. Later work has shown that a rapidly fatal re- sult is obtained only when the operation removes all of the thyroid tissues, and that the characteristic symptoms and their duration before a fatal termination depend somewhat upon the species of animal used and its age. In- human beings it is known that atrophy or loss of function in the thyroids leads to cretinism and myx- oedema, and that these distressing conditions may be removed completely by feeding thyroid tissue to the patient. In the lower animals the precise results of removal of the thyroids proper and of the parathyroids are not yet clearly known. Upon many animals, dogs, cats, rabbits, rats, operations that remove both the thy- roids and the parathyroids result in the rapid death of the animal with the symptoms of cachexia and muscular convulsions mentioned above. In the higher mammals (the monkeys, for instance), the symptoms are said to de- velop more slowly and to resemble more nearly the myx- cedema of man. One observer claims that in those animals, such as dogs, in which the fatal result of thyroidectomy is most prompt, a distinction may be made between re- moval of the thyroids and removal of the parathyroids. Removal of the former causes a slowly developing mal- nutrition, a progressive cachexia whose fatal termination may be long deferred. Removal of the parathyroids, on the contrary, occasions more acute symptoms including muscular convulsions and a rapidly, fatal result. This distinction needs, however, further confirmation before it can be accepted. It is stated also that the fatal outcome of complete thyroidectomy may be deferred or obviated completely by grafting a portion of the gland under the skin. These results upon man and the lower animals are usually explained upon the assumption that the thyroid tissues furnish an internal secretion which plays an im- portant and indeed essential part in the metabolism of the body, particularly perhaps of the nervous system. There is histological evidence to show that the colloid material contained in the vesicles of the glands is emptied into the lymphatics and thence reaches the blood. On the other hand, it has been proved that the beneficial material in extracts of the glands, is obtained from this same colloidal material. We may therefore regard this substance as a secretion which is discharged into the blood by way of the lymphatics. Bauman has succeeded in obtaining from the gland a peculiar organic compound containing iodine to the amount of nine per cent, of the dry weight. He designated this substance as iodothyrin and, showed that in the gland it exists in combination with proteid. Inasmuch as the iodothyrin, when used upon animals or patients, has much the same beneficial effect as the crude thyroid extract, we must believe that it represents one at least of the essential constituents of the internal secre- tion. How it or other substances affect normally the metabolism of the body is not yet explained. We know only that complete loss of this substance is followed by a perverted metabolism and finally by death. There is much evidence to show that feeding thyroid extracts to normal individuals leads to an increase in physiological oxidations, hence its use in cases of obesity. This fact is a further indication of the influence of its secretion on normal metabolism, but the' means by which it influences the nutrition of the cells cannot be determined without further work. The Adrenal Bodies.— Brown-Sequard was the first to show that removal of these bodies in dogs is followed by the death of the animal within a day or two. Subse- quent observers have confirmed this fundamental fact; and have shown that the symptoms preceding death are great muscular weakness, a loss of vascular tone, and a 101 Secretion. Secretion. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. feeble heart beat. On the clinical side these results agree well with the observation that in Addison's disease, which is accompanied by a lesion of the adrenals, there is also marked asthenia with feeble heart beat and loss pressure seems to be due to a direct action on the muscu- lature of the small arteries and veins, causing a contrac- tion and therefore an increase in peripheral resistance. This effect is only temporary ; in a few moments the press- WWWM^ &4 >-fc**t4i , il^'»iAili,i'iJi ; . &i ■&iz*J.^ilimoM*%M£.4e'. v ¥M YW' ,, * n ' /If 'W iiliiiiL iip^^vv, FIG. 4171. — Curve to show the Effect of Intravenous Injections of Extract of the Adrenal, when the Vagi are Intact. The time of the injection and the duration are represented by the white space on line D ; the effect on blood pressure and pulse rate is represented by line C ; the effect on the contractions of the ventricle and the auricle are represented respectively by lines A and B ; E gives the time in half -seconds. (Schaefer.) of vascular tone. As in the case of the thyroids physio- logical investigations of recent years tend to show that the adrenals produce an internal secretion of importance in metabolism, particularly the metabolism of the mus- cular tissues. Extracts of the medulla of the gland in- jected into the circulation of a normal animal cause a marked slowing and strengthening of the heart beat and a rise of blood pressure. The heart effect, so far at least as the slowing of the beat is concerned, is due to an action of the extract on the inhibitory centre of the vagus, since ure returns to normal, showing that the active sub- stance is quickly neutralized or destroyed within the body. This active substance in the medulla of the glands is normally secreted into the adrenal veins, since blood collected from these veins and injected into a normal ani- mal gives the effects described above. There is some evidence that the secretion of this substance is under the control of secretory nerve fibres. A number of investi- gators have attempted to isolate the active substance. Abel has succeeded in preparing from the extracts a basic FIG. 4172,-Curve to show the Effect of Intravenous Injections of Extract of the Adrenals when both Vagi are Cut. The designation of the curves is the same as in the preceding figure. (Schaefer.) it disappears on section of these nerves or after the ad- ministration of atropin. After section of the vagi injec- tion of the extracts causes a quickening of the heart rate and a great rise of blood pressure. The effect on blood 102 substance to which he gives the name of epinephrin and to which he assigns the formula Oi6H„N0 3 . The salts of this substance, when injected even in minute doses, give the characteristic effect upon the heart and blood- REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Secretion. Secretion. Other crystalline products — adrenalin and supra- renale— have been prepared from the extracts of the glands and used upon a commercial scale. They show very active physiological properties, but their exact composition and their relations to epinephrin are at pres- ent not fully determined. The conclusion commonly drawn from the above facts is that the adrenals secrete continually into the blood a substance that is normally necessary to the proper metabolism of the muscular tis- is, to substitute injections of the extracts in place of the normal secretion, have given negative or uncertain re- sults. This failure may be due to the fact mentioned above, namely, that the effect of injections is quite tran- sient. According to Battelli, continuous injections of adrenal extracts fail to prolong life to any noticeable ex- tent in animals whose adrenals have been removed ex- perimentally, and Christiani reports that grafts of the adrenals under the skin or in the peritoneal cavity fail i « 1 1 « 1 1 1 * » i M I HMI III l IjlWW W*W*IW»HW\Wrt Fig. 4173.— Curve showing the Effect upon Blood Pressure and Heart Beat of an Injection of an Extract of the Infundibular Body when the Vagi are Intact. The point of injection is shown upon line A ; IS is the blood-pressure record and C the time record in seconds. (Howell.) sues. When it is completely absent, as in removal or disease of the adrenals, a perverted metabolism ensues, and this expresses itself in a marked loss of muscular tone. The fatal result may possibly be attributed di- rectly to the effect on the circulation, the feeble heart beat, and the loss of vascular tone, giving a condition analogous to that caused by vascular shock. It should be added that some physiologists give a different inter- pretation to these facts. They hold that the normal function of the adrenals is to produce an antitoxic secre- tion capable of neutralizing or destroying certain poi- to ward off the rapidly fatal results of extirpation. The explanation of this last result, however, seems to lie in the fact that when the organ is grafted the medullary portion undergoes a retrogressive change, although the graft as a whole may seem successful. The marked ef- fect of adrenal extracts in causing vascular constriction has been utilized practically in producing local blanch- ing of vascular membranes in the case of the eye, nose, throat, etc. The Pituitary Body.— The pituitary body so called consists in reality of two quite distinct structures that JimuuiuiMiiiMiinmiiitnn ■ mnn i innM i mnnimiinn i nnni i MMn mmmmmmmmmmmmmmmm Fig. 4174.— Curve showing the Initial and Final Effect of an Injection of Extract of the Infundibular Body when the Vagi are Cut. designation of the curves is the same as in the preceding figure. (Howell.) sonous products of body metabolism, particularly the metabolism of muscular tissue. According to this view the fatal result of removal of the adrenals is due not to the absence of the normal stimulating or regulating action of their secretion, but to the accumulation of toxic products. This theory is designated sometimes as the auto-intoxication theory, but no convincing proof has yet been produced to show that in animals deprived of their adrenals there is present any toxic substance in the blood or the tissues. Attempts to use adrenal ex ■ tracts therapeutically in cases of Addison's disease, that possibly have different functions. The anterior lobe or the hypophysis cerebri is a glandular structure that de- velops in the embryo from the epithelium of the mouth cavity. The posterior lobe or the infundibular body is a mixed structure of nerve cells and glandular cells which develops from the infundibular process of the brain. It is very difficult to experiment upon these structures owing to their position. Vassale and Sacchi state that removal of the entire pituitary body is fol- lowed soon by a group of symptoms resembling those caused by thyroidectomy, namely, muscular tremors and 103 Secretion. [Body- REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. Segmentation of tbe spasms, apathy and dyspnoea, which soon result in death. It has been suggested, therefore, that the functions of this body may be related to those of the thyroid tissues, but no convincing evidence is at hand to make this view -probable. On the clinical side it has been asserted that the peculiar disease known as acromegaly is associated with lesions of the pituitary body, but a causal connec- tion between the two is still very uncertain. Injections of extracts of the body give results that vary with the lobe used. Extracts of the anterior lobe or hypophysis proper give little or no effect when injected into the cir- culation of a normal animal. Extracts of the infundib- ular lobe, on the contrary, give a marked effect upon the heart and blood pressure similar in many respects to that caused by extracts of the adrenals. This difference in the effect of the extracts suggests that the two bodies may have different functions in spite of their close ana- tomical connection. We have no direct evidence that these bodies furnish an internal secretion, but the absence in the adult mammal of a duct would imply that any product formed by them must affect the body by way of the circulation. Cyon, however, contends that the chief function of the pituitary body is to co-operate with the thyroids in regulating the blood flow through the brain. His idea seems to be that the pituitary body fulfils a double function. In the first place it serves as an auto- matic regulator of intracranial pressure, acting in two ways — mechanically, in that a rise of intracranial pressure stimulates the pituitary body and brings about a slowing and strengthening of the heart beat, and chemically, by secreting substances which act upon the vagus and accel- erator centres. In the second place it affects general metabolism also by an action of these last-mentioned substances on the vagi and sympathetic. For the ex- periments which lead him to this somewhat elaborate theory it will be necessary to consult the original pa- per, a reference to which is given at the end of this article. Internal Secretion of the Pancreas. — Few discoveries in physiology have been more interesting and significant than that made by von Mehring and Minkowski regard- ing the internal secretion of the pancreas. Briefly stated, they found that complete removal of the pancreas brings on a condition of serious glycosuria known now as pan- creatic diabetes. Acetone and /3-oxybutyric acid are also present in the urine, and, as in the diabetes mellitus of man, the animal shows polyuria and an abnormal thirst and hunger. These symptoms are followed by muscu- lar weakness, emaciation, and in a few weeks by death. If the pancreas is removed incompletely the glycosuria may be serious, or slight and transient, or absent alto- gether, according to the amount of the gland extirpated. If so little as one-fourth or one-fifth of the gland is left in the body the glycosuria may not show itself, and since the portion so left may have no connection with the in- testine, this fact as well as others shows that the mere suppression of the pancreatic juice has nothing directly to do with the diabetes that results from complete re- moval of the gland. In pancreatic diabetes the glycogen disappears from the liver. The blood shows an increase in its sugar contents from 0.15 per cent, to 0.3 or 0.5 per cent., and the urine may continue to contain sugar in quantity when carbohydrate food is withheld completely. On the basis of these and similar results it is believed that the pancreas forms an internal secretion which is given off to the blood. This internal secretion is sup- posed to play an essential part in the metabolism of the carbohydrates. It has been suggested, for instance, that the internal secretion contains an enzyme of some kind which is necessary for the dissociation or oxidation of the sugar of the body, so that in its absence the sugar accumulates in the blood and is lost through the urine. A specific form of this hypothesis has been advanced by Lepine. It has long been known that sugar in the blood disappears on standing, and Lepine has shown that this glycolytic action of the blood is due probably to the presence of a definite enzyme. He assumes that this glycolytic enzyme is formed intra vitam from the leuco- cytes of the blood, but that its formation is a function of the internal secretion of the pancreas. When the inter- nal secretion is prevented the blood loses its glycolytic power, and the sugar escapes oxidation. This hypothe- sis would seem to demand that in diabetes mellitus the glycolytic power of the blood, when tested out of the body, should be absent or distinctly below the normal. Several observers who have tested this point state, on the contrary, that the glycolytic action of diabetic blood is not less than that of normal blood. Other observers have adopted an entirely different view, holding that the pancreatic secretion normally regulates the output of sugar from the liver and other sugar-producing tissues. In its absence this output is increased and raises the sugar percentage in the blood to such an extent as to cause glycosuria. We must admit at present that the way in which the internal secretion of the pancreas af- fects the sugar consumption of the body is not known satisfactorily, although there is no doubt that in some way it is absolutely necessary in the process. Consider- Fis. 4175.— Section Through an Island of Langerhans. d. The gland cells of the surrounding pancreatic tissue : g, blood capillaries ; z, the columns of cells composing the island. (Kolliker.) able experimental and Histological evidence has accumu- lated tending to show that the cells concerned in this important function of the pancreas are not the pancreatic cells proper, but the so-called islands of Langerhans. In man these islands are scattered through the pancreas and form round or oval bodies that may reach a diameter of as much as 1 mm. The cells are polygonal and their protoplasm is pale and finely granular, while the nuclei show a thick chromatin network which stains deeply. In each island there is a capillary network resembling somewhat the glomeruli of the kidney. According to Ssbolew, ligation of the pancreatic duct is followed by a complete atrophy of the pancreatic cells proper, but does not affect to any marked extent the islands of Langerhans. Since under these conditions no glycosuria occurs, while removal of the whole organ including the islands is followed by pancreatic diabetes, the obvious conclusion to be drawn is that it is the re- moval of the islands that causes the pancreatic diabetes, and that therefore it is these cells that form the normal internal secretion of the pancreas. This conclusion is further corroborated by pathological results upon the lesions of the pancreas in human beings in connection with diabetes mellitus. A number of recent observers (Opie, Ssbolew, Herzog, et al.) find that in diabetes mellitus the islands are markedly affected. They show signs either of hyaline degeneration or of atrophy, and indeed may in severe cases be absent altogether. The Reproductive Glands. — The general interest in the subject of internal secretions in recent years was aroused largely by the work of Brown-Sequard upon the effect of testicular extracts (1889-92). The results of his exper- iments seemed to indicate that these extracts possess a marked stimulating or dynamogenic action upon the neuro-muscular apparatus. The effect was said to be 104 REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. Secretion. [Body. Segmentation of tlte pronounced not only upon sexual power but upon gen- eral muscular and mental vigor. Pohl claims to have obtained from such extracts a definite substance, spermin, to which he assigned the formula CdHuNs, and which he believes has a general tonic effect upon body metabol- ism. Similarly Zoth and Pregel report that these ex- tracts increase the power of doing muscular work when measured quantitatively by means of an ergograph. These and other similar experiments give us some reason to believe that the testes may form an internal secretion of importance in regulating and stimulating the metab- olisms of the body. If such a secretion is formed, how- ever, its action is not absolutely necessary to normal metabolism as is shown by the fact that castrated ani- mals live in apparently good health. Our natural infer- ence would be that a secretion of this kind might act as a regulator of sexual desire, but it is very uncertain whether such an effect takes place. In the experiments reported the possibility of suggestion playing a part in the results obtained is not excluded entirely, and we must speak therefore of the internal secretion in these glands as a possibility only and not as a demonstrated fact. The evidence is perhaps stronger that an internal se- cretion is formed by the ovaries. Loewy and Richter have shown that ovariotomy in dogs results eventually in a marked diminution in physiological oxidations as measured by the amount of oxygen consumed. And when an animal is brought into this condition, the admin- istration of ovarian extract is sufficient to bring the con- sumption of oxygen to its normal figure or to cause an increase beyond normal. Further probable evidence is found in the numerous gynecological cases involving the removal of the ovaries. Quite frequently in such cases disagreeable symptoms ensue, extreme nervous- ness, vaso-motor flushes, etc., and these results have been sufficiently marked to cause many gynecologists to be cautious in the removal of both ovaries. If one can be left the after-results of the operation seem to be less serious. This general fact, together with the undoubted influence of the ovaries upon menstruation and probably upon lactation, speaks strongly for the existence of an internal secretion ; but we lack at present definite scien- tific proof, such as we have in the case of the thyroids and adrenals. William B. Bmcell. References. The following general treatises contain references to the very exten- sive literature of the subject of secretions : Heidenhain In Hermann's Handbook der Pbysiologie, vol. v., part i., Langley, Edkins, Paton, Starling, Schaefer, Reid : Schafer's Text-book of Physiology, vol. i., 1898. An American Text-book of Physiology, vol. i., 1901. Howell, Chittenden, Adami, Putnam, Kinnicutt, Osier: Internal Secretions. Transactions of the Congress of American Physicians and Surgeons, fourth session, 1897. Pawlow : Die Arbeit der Verdauungsdrusen, 1898. Contains the litera- ture of the special work of the St. Petersburg laboratory, also English translation, 1902, by Thomson. Oppenheimer : Die Fermente und ihre Wirkung, 1900. Recent literature of importance not found in the abovesources, and used in the preparation of this paper are as follows : On the Mechanism of Pancreatic Secretion. Bayliss and Starling, Journal of Physiology, 1902, vol. xxviii., p. 325. See also Comptes rendus de la Socie'tecie Biologie, 1902, vol. liv.. No. 9. Cohnheim's Discovery of Erepsin. See Zeitscbrift f . physiol. Cnemie, 1901-1902, vol. xxxiii., p. 451 and vol. xxxv., p. 134. Beddard : On the Secretion of Urine. Journal of Physiology, 1902, vol. xxviii., p. 20. See also Gwaritch: Archiv f. d. ges. Physiol., 1902, vol. xci., p. 71, and Cushny : Journal of Physiology, 1902, vol. xxvii.p.429. . ./.,., For Cyon's theories regarding the hypophysis see Archiv f. d. ges. Physiologie. 1901, vol. lxxxvii., p. 565. *,,.».* For the recent work on the Relation of the Pancreas to Diabetes mellitus see Opie : Journal of Experimental Medicine, 1901, vol. v., pp. 397 and 527. Also Ssbolew : virchow's Archiv, 1902, vol. 168, p. 91 . SEDATIN, para-valeryl-amido-phenetol, para-valeryl- phenetidin, CeH 4 .OC 2 H 5 .NH.C4H 8 CO, is obtained by the action of valeric acid on para-amido-phenetol. It is in- soluble in water, sparingly soluble in ether, chloroform, and benzin, and readily soluble in hot alcohol. It is analgesic and antipyretic in dose of 0.2-0.7 gm. (gr. iij.-x.). Sedatin is also an old name for antipyrin. W. A. Bastedo. SEGMENTATION OF THE BODY— Segmentation of the body, or metamerism, is an expression used to convey the idea that the body is composed of a series of seg- ments, also called metameres, or somites, that are arranged in a series along the principal axis, and in each one of which the principal organs are repeated. Familiar ex- amples of metamerism are furnished by the earthworms and tapeworms. A better example is a typical marine annelid like Polygordius or Nereis, in which each somite, beside the integument, ventral nerve cord, main blood- vessels, and gut, which are continuous through the length of the body, has its own body cavity separated by a partition from its neighbors fore and aft, a pair of limbs (parapodia), a pair of nephridia, a pair of gonads, and several pairs of lateral blood-vessels and nerves, the same arrangement being found in each somite except the ter- minal ones. In the vertebrates there is an indication of a similar metamerism. Thus in all vertebrates the vertebrae, the ribs, and the spinal nerves are arranged metamerically , and in the fishes the trunk muscles are divided by transverse tendinous plates into myotomes, which are likewise meta- merical in arrangement. This metamerism of the muscu- lature is present to a less degree in the amphibia, but in the higher vertebrates, including man, it has almost dis- appeared in the adult, as the result, doubtless, of adap- tive modifications. But in the embryo metamerism is very evident, even in the highest forms, and has its foun- dation in the primitive segmentation of the mesoderm, forming the so-called protovertebrse. The divisions of the body being thus outlined at an early stage the spinal nerves, lateral blood-vessels, vertebrae, ribs, and the prim- itive nephredial tubules are developed in definite relation to them. The body of a vertebrate may be divided into three main regions — head, trunk (extending from the first cer- vical vertebra to the anus), and the tail. The segmen- tation of the trunk and tail is very evident in the em- bryo, if not in the adult, and the number of segments may be counted. Thus in man there are thirty -seven or thirty -eight originally, of which four or five are caudal segments that disappear during the second month of foetal life. The segmentation of the head is not so clear, even in the embryo, and has been a subject for earnest inves- tigation and discussion for a long time. While it is evi- dent that the head is a segmented structure, the actual number of segments and the organs appertaining to each one can be determined only after very minute compara- 'tive study of the development of the whole complex of muscles, nerves, ganglia, sense organs, and other struct- ures composing the head, and it is not surprising, there- fore, that there should be considerable difference of opin- ion. Thus Rabl denies that the head contains any segments in front of the ear that can be regarded as homologous with the trunk segments. This opinion is contrary to that of Minot and Hertwig, who regard the whole head as composed of homologous segments. But Hertwig estimates the number as nine, while Minot makes it thirteen. The segmentation of the body in vertebrates has been held to indicate the descent of this group from the anne- lids. Comparative anatomy shows, however, that the most primitive known allies of the vertebrates present no likeness to the annelids, but, on the contrary, re- semble in some respects the echinoderms, or rather their larva;; therefore the annelid theory of the origin of the vertebrates seems of very doubtful validity. It is more probable that the metamerism of the body arose independently in the primitive forms of the two groups in adaptation to a similar mode of. life. Robert Payne Bigelow. Bibliographical References. Froriep, A. : Entwickelungsgeschichte des Kopfes. Erg. Anat. und Ent., vol. i., 1892, Joe. ett., ill., 1894. Gaupp, E. : Die Metamerie des Schadels, loe. ctt., vii., 1898. Kupffer, C. von : Entwickelungsgechichte des Kopfes, loe. ctt., il., 1893; loc. cit., v., 1896. 105 Segmentation of the Ovum. REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. SEGMENTATION OF THE OVUM.— The segmenta- tion, or cleavage, of the ovum is the first stage in the de- velopment of an embryo from an egg. It begins with much smaller than the others. In the first case the cleav- age is said to be equal, in the second it is unequal. When the blastomeres are not of the same size, the smaller ones are called mieromeres and the larger ones macro- meres; and usually they differ in the parts they play in the development of the embryo. Equal cleavage D. E. H. FiQ. 4176.— Cleavage ol the Egg of an Irregular Sea Urclrin, Ecbinocardium. A, First cleav- age furrow; B, two-cell stage; C, begin- ning of second furrow ; D, E, four-cell stage ; F, third cleavage, two cells have divided and two are in process of division ; O, eight-cell stage complete ; J3, sixteen-cell stage, seen from animal pole; I, same from vegetative pole. Magnined. (After Fleischmann.) the first cell division after fertilization (or after the last maturation division in case of parthenogenesis, q. v.) and ends with the beginning of differenti- ation of organs (see Ovum, Gastrula, and Area embryonalis). The course of cleavage differs greatly in different groups of animals. Eggs having comparatively little deuto- Fig. 4178.— Egg of a Bat, Vespertilio Murina, in the Four-cell Stage. (After Van Beneden and Julin.) is found in the eggs of sponges, coelenterates, echino- derms (Fig. 4176), truncates, amphioxus, and mammals (Figs. 4177 and 4178), and in some annelids, Crustacea, I B \ \ %A ~y Fig. 4177.-Egg of a Babbit of Twentv-four f, " rs L th ? flrst cleavage has been completed. (After Coste.) plasm, or yolk, divide completely into two, four, eight, sixteen, . . . etc., cells. The cleavage is then said to be total, and the egg is described as holo- blashc. The cells derived from the di- vision of the ovum are called blasto- meres. The blastomeres may be very nearly of the same size or some may he 106 ZrA '-. ™> /$*<"■ < fc * i m W '^^S5h Fig. 4179.-Segmentation of the Frog's Egg and Formation of Blastopore. A, Eighteen stage ; B, beginning of sixteen-cell stage ; C, thirty-two cell stage ; Z>, forty-eight cell stage (unusually regular); E, F,G, later stages ; & J, stages iff the formatton of tte blastopore. Magnified. (From Morgan.) wnLumuu REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. Segmentation of the Ovum, and molluscs. Unequal cleavage is typical of the an- nelids, molluscs (Pig. 4180), lampreys, gonoid fishes, and amphibia (Fig. 4179). Other animals produce eggs that contain a very large proportion of deutoplasm. In such cases only a part of la A K'T F\ a 1C fplil fcf" ld ,!J ld"''1b'<< "- ■■ x ^ J - ; M"' f-2t $J1P^ : . -zb' -ay 3b "'^^m^^^m P^ o 'b VA FIG. 4180.— Two Stages in the Development of Crepidula. Upper figure, four-cell stage viewed from above ; lower figure one hundred and nine-cell stage, viewed from the side. I. and II., first and second cleavage furrows ; A, B, C, J>, macromeres ; la, lb, le. Id, micromeres ; as, aster. Highly magnified. (From Conklin.) the egg undergoes segmentation, the rest of the yolk di- viding incompletely and being finally absorbed as food by the growing embryo. This form of cleavage is called partial, and the egg is described as meroblastie. Meroblastic eggs may be centrolecithal, having the yolk chiefly at the centre, or telolecithal, having it concentrated toward the vegetative pole (see Ovum). Centrolecithal eggs have a superficial cleavage, the blastomeres forming a layer of cells, the blastoderm, surrounding the unseg- mented yolk. This form of cleavage is characteristic of the arthropods. Telolecithal eggs have a discoidal cleav- age, the blastoderm forming a disc at the animal pole of the egg. This is the form of cleavage to be found in the eggs of cephalopods (Fig. 4181), sharks and rays, bony fishes, reptiles, and birds (Fig. 4182). The position of the planes of cleavage depends some- what upon the type of the egg. In centrolecithal eggs the cleavage nucleus takes a position near the centre of the egg previous to division. Then follows a number of nuclear divisions without division of the cytoplasm. The resulting nuclei migrate to the surface of the egg, and the mass of cytoplasm gathered around each nucleus be- comes separated from its neighbors by cleavage furrows starting from the exterior. In alecithal and telolecithal eggs the first two planes of cleavage are always at right angles to one another and cross at the animal pole of the egg (Fig. 4176, A, E). In the subsequent stages there are developed three types of cleavage — radial, spiral, and bilateral. As examples of the radial type we may take the eggs of sea urchins and of frogs, both holoblastic eggs, the one having equal cleavage, the other unequal. Any one provided with a good microscope can easily observe the cleavage of the eggs of sea urchins or of starfish. The eggs are obtained by cutting up the ovaries of a ripe female. If these are placed in a dish of clean sea water and a small piece of the testis of a ripe male is cut into small pieces and mixed with the eggs, fertilization will take place, and then it re- quires only a little patient watchiDg of eggs placed from time to time under the microscope for one to observe all A. E. F. Fig. 4181.— The Discoidal Cleavage of the Egg of a Squid. A, TJn- segmented egg and polar BtSffles; B, first cleavage furrow ; C,D,E, later stages ; F, eight-cell stage viewed from the animal pole and showing the marked bilateral symmetry of the cleavage furrows. X 30. (After Watase\) stages up to the formation of the larva. Freshly laid and fertilized frog's eggs may be obtained by careful search of the ponds in early spring. By packing the eggs with ice, development may be delayed until the laboratory is 107 Segmentat io n . Semilunar Ganglia. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. reached. After the eggs have been placed in fresh water at the normal temperature, the cleavage will proceed and may be followed easily with a hand lens or a microscope. The first indication of cleavage is the appearance of a slight furrow at the animal pole— the position of the polar body in the echinoderm's or the centre of the black half fig, 4182.— Four Stages of the Segmentation of the Hen's Egg. Only the germinal disc, seen from above, and part of the surrounding yellow yolk are represented. (After Coste.) in the frog's egg. This occurs in the frog's egg between two and a half and three hours after fertilization. This furrow quickly deepens and extends around the egg to the other side (Fig. 4176, A and B). Sections of an egg made just before and during this stage show that the nucleus had divided previously by a typical mitosis, and that the plane of cleavage is at right angles to the spindle, so that each blastomere contains one of the daughter nuclei. During the division the blastomeres become more or less rounded. But when it is completed they flatten against one another, so that the line of division becomes indistinct, and the egg rests for a time. At the end of the resting period, about three-quarters of an hour after the appearance of the first furrow in the frog, the blasto- meres round up again and the second furrow makes its appearance at right angles to the first at the upper, ani- mal, pole of the egg (Fig. 4176, C-E). This furrow ex- tends around the egg like the first, dividing each blasto- mere into two. The egg is now in the four-cell stage. After another period of rest, the third cleavage furrow appears in a horizontal plane at right angles to both the first and the second. In the echinoderm egg this is very nearly at the equator of the egg, but in the frog it is some- what above the equator, so that in the eight-cell stage we find four black micromeres and four white macro- meres. Compare i^and 67, Fig. 4176 with A, Fig. 4179. The fourth cleavage in the frog occurs from one-half to three-quarters of an hour later. When this is regular each blastomere is divided into two in a plane at right angles to the preceding one. The planes of division form two great circles bisecting the angles between the first two. But in the frog the eggs are seldom so regular as this and the following cleavages are quite irregular (Fig. 4179). The spiral form of cleavage is characteristic of the worms and molluscs (Fig. 4180). In these groups the third cleavage plane is not a con- tinuous horizontal circle, but is tilted in each blastomere, to the left usually, looking at the egg from the side. Thus the blasto- meres of the two quartets in the eight-cell stage do not lie directly one above the other, but they break joints. The lines of divis- ion in the next cleavage are tilted in the opposite direction, and are thus at right angles to the preceding ones. This alter- nation of spirals may continue for several generations of cells. In these forms the blastomeres are frequently unequal to a marked degree, and the rhythm of cleavage may vary in the blastomeres of different sizes, with the result that there is de- veloped a very complex type of cleavage. In the bilateral form of cleav- age there is but one plane of symmetry, usually coinciding with the first cleavage furrow. The blastomeres are arranged in a bilaterally symmetrical pattern on the two sides of this plane. This form of cleavage is found in both holoblastic and mero- blastic eggs, namely, those of tunicates and cephaiopods (Fig. I 4181). The cleavage of the hen's egg I is not easy to observe, for it takes I place before the egg is laid, but I it appears to be of an irregular I radial type. As in other mero- I Mastic eggs, the earlier cleavage I furrows are incomplete, so that the blastomeres are not separated from the undivided 1 yolk. It is only after several radial furrows have formed I that concentric ones appear, dividing the blastomeres into I a central group of superficially complete ones surrounded I mmhhhm somatic cells Fig. 4183.— Diagram representing the Determinate Segmentation of the Ovum of Ascaris. Z, Fertilized egg ; Pi, P,, etc., protogonocytes ; G, primordial germ cell (P 8 , Fig. 2614, article Heredity) ; S,, S a , etc., primary somatic cells; A. and B, primary ectodermal cells; o, 6, daughter cells of the right side ; a, 0, of the left side ; E, primary endodermal cell ; M, cell which produces mesoderm and part of ectoderm. (Modified from Boveri.) 108 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Segmentation. Semilunar Ganglia. by a circle of larger blastomeres still connected with the yolk at the surface (Fig. 4182) ; and it is still later when a horizontal division occurs, separating the central blasto- meres from the yolk beneath. The segmentation of the ovum differs also among the various groups of animals in being either determinate or indeterminate in character. Typically determinate types of cleavage are found in the eggs of worms (Fig. 4183) and molluscs. In these forms the cleavage is often very complex, and at first glance appears very irregular, but careful study shows that each cell division follows a law that is perfectly definite within the species. Thus the history of each cell may be traced from the first cleavage to the formation of the organs. Conklin, for example, has constructed a remarkable genealogical tree showing the history of each cell in the eggs of Crepidula, the com- mon slipper shell, to the one-hundred-and-nine-cell stage (Fig. 4180), and from the groups of cells present at that stage he was able to observe the development of various important organs. In the echinoderms and vertebrates, on the other hand, the cleavage soon becomes irregular and no one has suc- ceeded, so far, in tracing the history of the blastomeres. So, for the present, the cleavage of these forms must be regarded as indeterminate. In the frog it has been found that the first cleavage furrow coincides with the princi- pal axis of the body, but this rule is not true for all in- dividuals. So we cannot say that even the first two blas- tomeres always give rise to certain parts of the body. Bobert Payne Bigelow. Bibliographical References. Conklin, E. G. : Embryology of Crepidula. Journ. Morph., vol. xiil., 1697, pp. 1-226. Morgan, T. H. : Development of the Frog's Egg. New York, Mac- millan, 1807. Wilson, E. B. : The Cell in Development and Inheritance, second edition. New York, 1900. SEIGLER'S SPRINGS. — Lake County, California. Hotel. These springs are located at the foot of Seigler Moun- tain, at an elevation of 2,372 feet above the sea. They are in the neighborhood of Adams and Bonanza Springs, and lie in Seigler Valley, which is about one mile and a half long by half a mile in width. The surrounding country affords many excellent drives, and magnificent views are encountered on every hand. There are twenty or more springs, which yield approximately three thou- sand gallons per hour. The " Arsenic " Spring has a temperature of 96° F., and is much used for syphilis, scrofula, and cutaneous disease. The " Soda " Spring is alkaline and carbonated, and forms a delicious drinking- water. It has been much in vogue for Bright's disease, bladder troubles, etc. The " Magnesia " Spring is heav- ily charged with Epsom salts and carbonic acid gas. A glassful before breakfast insures an easy and painless evacuation of the bowels. The Sulphur Spring is mostly used for bathing and for lung, liver, and rheumatic trou- bles. There are very good accommodations at the springs. James K. Crook. SEMILUNAR GANGLIA, PATHOLOGY OF.— A search through the literature of recent years for the results of work on the pathology of the semilunar ganglia is not very satisfactory. The facts that these organs are such near neighbors of the suprarenal capsules and the pan- creas, and that they have such intimate nervous relations, especially with the former, have led to many efforts to establish their pathological association; but these at- tempts seem to have failed of convincing demonstration, the conclusions reached being largely theoretical. The result is that while the journals contain many articles showing extensive research and experimentation and faithful observation of cases and autopsies, the number of established facts bearing on this subject which can be found in the systematic treatises is small and disappoint- ing. Romberg was among the earliest to ascribe to the semilunar ganglia definite pathological manifestations. Under the title of Neukalgia Cgsliaca he describes " a sudden and violent epigastric pain or one preceded by a sense of oppression. It generally extends to the back and there are a sense of fainting, cold extremities, and small intermittent pulse. The region of the stomach is either swelled or sunken and the abdominal parietes are tense. Pulsation at the epigastrium is common. Press- ure gives relief. Sympathetic sensations occur often in the thorax, under the sternum, or in the pharyngeal branches of the vagus, but seldom in superficial parts. It lasts for from five minutes to half an hour, and is suc- ceeded by extreme exhaustion. If it breaks off suddenly it is followed by eructations of gas or fluid, by vomiting, gentle perspiration, or copious enuresis. The suppres- sion of accustomed hemorrhages gives rise to it, also it often precedes rheumatism and melsena. Gout predis- poses to it, and the development of carcinoma ventriculi is often preceded for years by cosliac neuralgia. The peculiar sense of fainting and annihilation which accom- panies it is pathognomonic of this disease, and distin- guishes it from such neuralgia of the vagus as is in- cluded in the term cardialgia. " Byron Robinson also includes neuralgia coeliaca among the functional disturbances connected with the semilunar ganglia. After remarking that "there may be post- mortem findings of lesions of the sympathetic, but these may not have been preceded by records of physical com- plaints in life, and they may be secondary, " he continues : " Hypersesthesia or exalted irritability of the sympa- thetic nerves is liable to manifest pain irregularly, peri- odically, spasmodically, and yet retain some irritability during the intervals. ' Anatomically we know little of the characteristic changes in structure in hypersesthesia. Its etiology also is obscure, although malnutrition is probably a bottom fact. The active hypersesthesia of the great ganglia of the sympathetic system is character- ized by an overpowering sense of prostration, a sense of impending dissolution, as if the centre of life would be destroyed." These views are quite in line with those of Romberg, and correspond closely with those given by F. A. Hoffmann in discussing the diagnostic significance of subdiaphrag- matic pain. He considers radiating pain as characteristic of irritations, of the retroperitoneal structures as distin- guished from those originating in affections involving the mucous membranes or the parenchyma of organs, the muscular tissue of hollow organs, or the peritoneum. Moreover, he finds that the tendency of pain originating in the aorta, the adrenals, and the solar plexus is to ex- tend downward. He finds that little attention has been paid to a neurosis of this plexus, although it is one com- prising very numerous sympathetic filaments, and the neuroses of which must exhibit sensory, motor and vaso- motor lesions, suggesting the analogue of migraine: The characteristic site of the pains which belong to a neurosis of the cceliac plexus is the upper part of the ab- domen, and from this point they radiate to the sacral and gluteal regions behind, but not to the genital organs or legs in front. These, with sheeps'-dung fseces and polyuria form a group of symptoms pointing, in the absence of hysteria and tabes, to a diagnosis of a neurosis of the cceliac plexus. He cites three cases in support of his views, two of his own, in which the symptoms men- tioned were present, and I would call special attention here to the excessive discharge of urine of low or mod- erate specific gravity (1.008-1.012) containing neither albumin nor sugar and unaccompanied by great thirst, as one of the pathological features ascribed to the semi- lunar ganglia. With reference to the pathological relations said to exist between the semilunar ganglia and the kidneys, as shown in the occurrence of diabetes insipidus, the follow- ing quotations voice the prevailing opinions: Shapiro says, "that physiologists ascribe an especially weighty influence to the splanchnic nerve in regulating the quan- tity of urine secreted by the kidneys. " He gives the his- tory of a case of diabetes insipidus, the patient .having 109 Semilunar Ganglia. Semilunar Ganglia. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. also pulmonary tuberculous disease and becoming greatly- emaciated. " The autopsy showed no interstitial inflam- mation, nor amyloid degeneration of the kidneys, nor pathological changes in the brain or spinal cord, by which the polyuria could be explained, but the micro- scope revealed noticeable changes in the peripheral ner- vous elements of the kidneys. The cceliac plexus seemed to be surrounded by a bundle of small lymph glands. The most interesting changes were found on microscopic examination of the cceliac ganglion. There seemed to be thick bundles of connective tissue crossed with many granules. On section, there were seen many enlarged and developed vessels in the neighborhood of which the gan- glion cells were distinctly diminished, shrunken, and sepa- rated from the capsule. All the cells showed a marked mass of granular pigment. There was also pigment ac- cumulation in the interstitial connective tissue ; also fatty degeneration of the axis cylinder of the splanchnic nerve. " In this connection it is well to recall the anatomical rela- tions of these nerves and ganglia, viz., that the upper part of each semilunar ganglion is joined by the greater and lesser splanchnic nerves, filaments from them going to . the renal plexus and suprarenal gland; also to the inner side of each semilunar ganglion the branches of the solar plexus are connected. The cceliac plexus is a direct con- tinuation of the solar plexus (Gray 's " Anatomy "). Fut- cher quotes from Ralfe as follows: "The sympathetic plays the most important role among the peripheral nerves in the etiology of diabetes insipidus. . . . The nerves forming the renal plexus are derived chiefly from the solar plexus. As the right vagus and greater and lesser splanchnics join the solar plexus, it is probable that branches of these nerves enter the kidney by way of the renal plexus. Dickinson reported a case of diabetes insipidus in a patient with carcinoma of the liver and in- volvement of the solar plexus ; carcinomatous metastases were found in the retroperitoneal glands which involved branches of the solar plexus. There was marked hyper- emia of the kidneys. . . . Ralfe also refers to tumors pressing on the thoracic and abdominal nerve ganglia, which probably agree in disturbing the vaso-motor gov- ernance of the renal vessels. " Pigmentation of the skin, notably that observed as a feature of Addison's disease, has also been ascribed patho- logically to the semilunar ganglia. Byron Robinson in- cludes it in his list of the functional disturbances of these organs. Thompson says : " The fact has been confirmed by many observers (Lancereau, Nothnagel, Fleiner, and others) that the pigmentation occurs most prominently in those cases [of Addison's disease] in which the sym- pathetic nerves are found diseased." Byrom Bramwell quotes two French observers, Alezais and Arnaud, as concluding that the essential cause of the pigmentation and other characteristic symptoms of Addison's disease is implication of the pericapsular nervous ganglia, which they describe, by a tuberculous process extending from the adrenals. Marchand, on the other hand, reports in extenso a case of disease involving the sympathetic nerves, the suprarenal capsules, and the peripheral nerves, with- out any bronzing of the skin. Fleiner also reports cases of bronzing of the skin in which there was found no disease of the adrenals, although the cases were ranked as Addison's disease. In fact, until very lately among German writers the pigmentation seems to have been generally regarded as a regular feature of the disease, and the name " bronze Haut " used for it. T. H. Green, how- ever, says that " the cause of the pigmentation in Addison's disease is not satisfactorily explained. Irritation of the abdominal sympathetic is believed to cause increased pigmentation, and the pigmentation in Addison's disease is merely an exaggeration of the normal." The trend of opinion most recently, however, appears to be that the pigmentation does not belong to Addison's disease as an essential feature, though it may often be noted in connection with it, very probably because of irritation of the sympathetic plexuses and ganglia in the vicinity of the adrenals, which are so often involved in the morbid processes associated with that disease. Neus- 110 ser says that the formation of pigment in man is con- trolled by the vaso-motor nerves; in other words r by the sympathetic system acting through the medium of chromatophore cells. Every case of " bronzed skin " does not j ustify the diagnosis of Addison's disease. Pig- mentation is due to a disturbance of innervation in the sympathetic tract. The pathology of Addison's disease has been held to be closely related to the semilunar ganglia since the earliest commentaries were written on the group of symptoms to which that name was given. Thomas Addison's original essay on " The Constitutional and Local Effects of Dis- ease of the Suprarenal Capsules " speaks of an abnormal condition of the semilunar ganglia in but one case, in which they were the seat of fatty degeneration. The writer of the introduction to this essay in the New.Syden- ham Society 'sedition remarks that Addison merely noted the correlation as cause and effect of the post-mortem findings of diseased capsules with the group of symptoms he had observed during life, for which he had been able to find no satisfactory explanation. He adds that "true Addison's disease has essential peculiarities of its own, and those not belonging to tuberculous or cancerous capsules." Rolleston quotes Habershon as the first to show that as a result of inflammation spreading from the suprarenal bodies the semilunar ganglia and their branches may become surrounded by dense fibrous tis- sue. Subsequently to this, and based to a greater or less extent upon the fact noted by Habershon, arose many theories of the pathological relations supposed to exist between the adrenals and the semilunar ganglia,, and to account for the various symptoms grouped under the name of Addison's disease. It will be necessary to refer to the more prominent of these, and to some of the cases cited and the arguments adduced for and against them. One of the chief theories was called the "nervous," and Eulenburg and Guttmann say that it "regards Addison's disease as depending on an affection of the nervous system, especially of the great abdominal plexuses of the sympailietic. . . . The ganglion semilunare sends a considerable num- ber of twigs to the suprarenal bodies and these form a close network, which is, as Virchow discovered, richly supplied with ganglia. . . . These observations te/id to strengthen the theory that Addison's disease is intimately connected with structural changes in the sympathetic. This is not supported, however, by any very good phy- siological reason. . . . Still, patliological anatomy has furnished some support for this theory. . . . The results of the examination of the sympathetic still remain, how- ever, antagonistic to each other, at one time negative, at another positive. But even should the positive evi- dences accumulate in the future, or if it be shown that the changes in the plexuses of the sympathetic are pri- mary and those of the suprarenal capsules secondary phenomena, the question would still be how the symp- toms of Addison's disease are caused by such changes, a question toward the solution of which we have not advanced one step." This question had to wait some twenty years for an answer. I quote from Fleiner some account of the pathological findings in two cases of Addison's disease to show in a measure on what this discussion was based. He says : " The facts have been observed that well-marked cases of ' bronzed skin' have post mortem presented no pathologi- cal conditions in the adrenals, and, on the other hand, in spite of pathological findings in the adrenals after death the patients presented no symptom of the disease during life." Fleiner reports two cases of Addison's disease, one slightly and the other much advanced. In the first case on post-mortem examination, tuberculosis of both adrenals was found and noticeable enlargement of the semilunar ganglia. In the second case, there was angiosarcoma of the left adrenal, which constituted a metastasis of an ex- traperitoneal tumor. Here the semilunar ganglia were diminished in size. In both cases microscopical examina- tion showed inflammation as well as degeneration of the medullary nerve fibres, not only in the semilunar ganglia REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. Semilunar Ganglia. Semilunar Ganglia. but in the whole upper regions of the sympathetic as well as also in the intervertebral ganglia. He also speaks of the degenerative changes in the splanchnic, the cervical ganglia and portions of the posterior columns of the cord, at the entrance points of the posterior roots and in the peripheral nerves. He then expresses the opinion that the principal groups in the symptom complex known as Addison's disease— viz. : (1) The lesions on the part of the digestive organs; (2) the manifestations on the part of the nervous system; (3) the pigmentation — can be sat- isfactorily explained by the facts he has brought forward in discussing these cases. Asa summary he concludes " that for the reasons he has given he feels warranted in regarding as characteristic of Addison's disease a condi- tion of chronic inflammation, which, advancing from the degenerated adrenals, exhibits its highest degree in the semilunar ganglia of the sympathetic and in the inter- vertebral ganglia, and is appreciable in slighter degrees in the ganglia of the pectoral sympathetic and in the cer- vical ganglia, and which is emphasized in connection with the alterations in the connective tissue, especially in an intense atrophy of the ganglion cells and in an extensive degeneration of the medullary nerve filaments in the sympathetic and in the splanchnics." As opposed to these views we find C. Alexander quoting Kahlden to the effect that the assumption that certain symptoms of Addison's disease are referable to the semilunar ganglia is false, that the coeliac ganglion has nothing to do with Addison's disease. He also calls attention to the fact that in various other dis- eases the semilunar ganglia are involved in pathological changes, as shown by Hale White. That author made microscopical examination of the cervical sympathetic and semilunar ganglia in thirty -three patients dying from various diseases, such as diabetes, cancer of the bladder, aortic disease, sarcoma of the pelvis and breast, chronic Blight's disease, phthisis, tumor of the brain, diphtheria, anthrax, myxcedema, cerebral hemorrhage, etc. "Of the thirty-three semilunars three came from children, and in all of them the ganglion cells were excellent examples of normal nerve cells, some of them showing processes as distinct as those of the cells of the spinal cord. In six only of the remaining thirty were all the nerve cells nor- mal; all the other ganglia showed more or less degenera- tion of their cells, which in many sections were reduced to minute masses of non-nucleated granular pigment, free in the middle of the capsule. Often there was a large amount of fibrous tissue. In a few instances the section was crowded with leucocytes, but no cause for this could be made out. . . . "We may probably conclude that although the semilunar ganglia in the lower mam- mals and in young human beings are functionally active, in human adults their nerve cells have degenerated and become functionally inactive, but the nerve fibres always retain their structure and function. " So much of the discussion we are tracing out turned upon the question whether the pathological changes in the semilunar ganglia were primary or secondary to those in the suprarenal capsules that I quote the views of Long Pox as follows. He says : " The sympathetic often gives in its coarser lesions evidence that the influence is not that of the sympathetic on disease, but of disease on the sympathetic and its ganglia, and cites such instances as inflammation of the semilunar ganglia associated with headache, increase of their size in case of a tuberculous suprarenal capsule or of cancer of the stomach. Such secondary lesions may in their turn excite certain reflex phenomena, such as flushing, sweating, faintness, palpi- tation, diuresis. Also the sympathetic, in its character as a connecting link for function between all organs, and subject to various influences, perhaps emotional, perhaps due to altered conditions of the blood, may modify the functional activity of a ganglion or series of them, leav- ing them even microscopically unchanged. These effects may be motor, sensory, or vaso-motor manifestations." Ziegler also supports the statements of Pleiner and others as follows: "Inflammation of the sympathetic ganglia and fires induces changes in these structures sim- ilar to those produced in the spinal nerves. Thus tuber- culous caseation of the suprarenal capsules extending to the surrounding tissue sometimes leads to inflammation and proliferation in the solar plexus and semilunar gan- glia, resulting in degeneration of the fibres and ganglion cells of the sympathetic. So, too, tuberculous disease of the bones of the vertebral column is apt to extend to the sympathetic nerves and ganglia." Bramwell distinctly favors the view that the changes in the semilunar ganglia are secondary. He says : " The nerves which pass in such abundance between the cap- sules and the semilunar ganglia themselves are in a con- siderable proportion of cases implicated in these inflam- matory changes. On naked-eye examination they may ' be seen to be enlarged, thickened, indurated, and some- times injected and redder than normal. On microscopic examination appearances clearly indicative of inflamma- tory induration (increase of connective tissue, infiltration with leucocytes, enlargement and engorgement of the blood-vessels) may be present in the fibrous covering of the nerves; in some cases the proper nervous elements (nerve tubes and ganglion cells) are also inflamed, degen- erated, or atrophied. These inflammatory changes in the nerve tubes and semilunar ganglia are probably second- ary. Sometimes no pathological alterations have been found in the semilunar ganglia or large nerve trunks forming the solar plexus, even when the adrenals have been completely destroyed, and in other cases the solar plexus has appeared quite normal when the adrenals have been completely atrophied, absent, or replaced by fat." Thompson's study of Addison's disease leads him to the conclusion that the group of symptoms characteristic of the disease, while all pointing to a common origin in a lesion which excites or irritates the sympathetic nervous system, yet are not necessarily referred to the semilunar ganglion alone, but at times to the stomachic,- hepatic, or mesenteric plexuses, including irritation of the diseased suprarenal capsules. In a small proportion of cases the adrenals may even remain normal, while the sympathetic nerves and ganglia are alone diseased. When opinion had reached about the stage represented by authors as quoted above, certain new conceptions and explanations of facts previously observed were brought forward, notably by Rolleston. Attention had been called by Jaboulay to the occurrence of accessory suprarenal glands sometimes to be found upon the semilunar gan- glion and in the midst of the solar plexus, and it had been suggested that their presence might explain the absence of the symptoms of Addison's disease in some cases in which the capsules themselves had been found seriously degenerated. Rolleston says " they are often so small as to be found only when parefully looked for, about the size of a grain of corn attached to the main organ by vas- cular tags and perhaps due to compensatory hypertrophy when the main organ is in a state of caseous degenera- tion. " He quotes Wilks and Greenhow as believing that the lesion is primary in the suprarenal capsules and al- ways of the same nature, while the symptoms of the dis- ease are due to the secondary effect on the adjacent sym- pathetic, the solar plexus, and semilunar ganglia. As to the question of the " nervous theory " he concludes that " it is untenable ; it does not explain the numerous cases recorded of typical Addison's disease, in which special attention has been paid to the condition of the semilunar ganglia and adjacent sympathetic, and in which they have been found to be normal, since a continued irritation could not last for any time without setting up inflam- matory changes in situ." The following quotation from Rolleston indicates the introduction into the discussion of the relations of the semilunar ganglia with Addison's disease, of a new ele- ment. It originates in the greater attention paid during recent years to the study of the ductless glands and the results which follow when their secretions are prevented from fulfilling their exact offices in the economy. Rol- leston says : " Obstruction to the efferent vessels of the suprarenal capsules is quite a possible cause of Addison's 111 Seminal Incontinence, .^^^^j, HANDB 00K OF THE MEDICAL SCIENCES. Senega disease." At this point the following of more recent date from Hektoen will show the growth of new views. He says: " Because Addison's disease occurs without any apparent changes in the adrenals, and because the adre- nal changes present often involve the abdominal sym- pathetic, it was attributed to chronic degenerative and inflammatory changes in the semilunar ganglia and ab- dominal sympathetic " (Wilkes, Jaccoud, Tizzoni, Sem- mola). This "nervous theory " quite held the field until recently ; but the changes described by some in the nerves are frequent in apparently healthy individuals (Hale White, quoted above), and extensive chronic fibrous in- flammation in the vicinity of the adrenals might lead to destruction of the efferent vessels, the sequence of events being comparable to Bonnet's experimental ligature of the veins of the adrenals with fatal effects. Addison's disease may occur without any changes in these nerves." It has been almost impossible amid all these often con- flicting theories to disentangle the pathological relations of the semilunar ganglia to the adrenals from those of ihese latter bodies to degenerative processes in themselves ir to the result of pressure upon their efferent vessels by external agencies. It seems justifiable to express the be- lief, however, that the semilunar ganglia can no longer be regarded as the sole or chief and efficient causes of Addison's disease. Osier, in fact, in 1896 wrote as fol- lows: "Although the view of disturbed innervation con- sequent upon the involvement of the abdominal sympa- thetic meets the case theoretically better than any other and is at present widely held, yet there are signs of a re- turn to the old view of Addison." Most recently, however, we have in Neusser's article such an elaborate and important review of Addison's disease, with independent and theoretical developments also, as cannot be overlooked, although a few brief ex- tracts must suffice. As far as they concern the special topics treated in this article the following embody some of his conclusions and the reasons for them. He quotes from Brauer the opinion that there is no constant relation between Addison's disease and changes in the sympa- thetic, but reasons out the relations which he regards as intimate though not quite clear between the adrenals and the cceliac ganglion in this way : " Lesions of the sym- pathetic system have been observed both in connection with and in the absence of disease of the suprarenal cap- sules. They may affect, first the sympathetic ganglia in the substance of the suprarenal capsules and the pericap- sular ganglia occasionally present, then the nerve fibres running from the suprarenal bodies to the cceliac gan- glion, the ganglion itself, and the solar plexus, in addition to the sympathetic tracts extending from this point even as far as the cervical ganglion of the ganglionated cord, and finally the splanchnic nerve. . . . Many of these changes are dependent upon tuberculous disease of the suprarenal bodies and the resulting cicatrization. ... In every case the symptoms of Addison's disease result from impairment or eventually complete suppression of the functions of these capsules brought about by disease of these capsules themselves or of the nerve tracts control- ling their function. This impairment of function causes most symptoms. " Although this exposition throws the light of modern physiological research upon the question that has occu- pied us, still it cannot be considered so complete or simple as to be wholly satisfactory, although it does clear away many of the mists of the last half-century. Neusser's article is most careful, comprehensive, and readable, and has the fullest possible bibliography. J. Haven Emerson. Bibliography. Addison, Thomas, Collection of the Published Writings of, London, 1868, New Sydenham Society. Alexander, C. : Die Nebennieren und d. Bezieh. z. Nervensystem. Ziegler's Beitr., xi., 1892. Bramwell, Byrom : Anaemia and Some of the Diseases of the Blood- forming Organs and Ductless Glands, Edinburgh, 1899. Brauer, L. : Deutsche Zeitschr. f. Nervenheilkunde, 1895, vii., Hefte 5 u. 6. Bulenburg and Guttmann : Physiology and Pathology of the Sympa- thetic Nervous System. Transl. by A. Napier, London, 1879. Fleiner, W. : Ueber die Veranderungen des sympathischen u. eere- brospinalen Nervensystems bei der Addison'schen Krankhelt, in Deutsche Zeitschr. f iir Nervenheilkunde, vol. ii., 18^1-92. Fox, Edward Long : Influence of the Sympathetic on Disease. Med. Times and Gazette, September 2d, 1882. Futcher, J. B. : Johns Hopkins Hospital Reports, vol. x., 1902. Green, T. H. : Pathology and Morbid Anatomy, Philadelphia, 1900, p. 79. Greenhow, E. H., on Addison's Disease, being the Crooman Lectures for 1875, London, 1875. Habershon : Guy's Hospital Reports, 1861. Hektoen: American Text-book of Physiology (Hektoen and Ries- man), Philadelphia, 1901. Hoffmann, F. A. : Ueber hypophrenische Schmerzen u. Neurose der Plexus Coeliacus. Munchen. med. Wochensch., February 18th, 1902. Jaboulay : On Accessory Adrenals Situated on the Semilunar Ganglia, etc. Lyon. M^d., November 2d, 1891. von Kahlden : Virch. Archiv, 114, 1888, p. 67. Lloyd, J. H. : Diseases of the Cerebro-spinai and Sympathetic Nerves. Twentieth Century Practice, New York, 1897, xi., 3, 476. Marchand, F. : Ueber eine eigenthumliche Erkrankung des Sympa- thicus, der Nebennieren u. der peripherischen Nerven (ohne Bronzhaut). Virch. Archiv, 81, 1880, p. 477. Neusser, E. : Addison's Disease, in Nothnagel's Encyclopedia of Practical Medicine, American edition, 1903, vol. ix. Osier, W. : Internat. Med. Magazine, vol. v., 1896-97, p. 3 ; Practice of Medicine, third edition, New York, 1898. Ralf e : Allhutt's System of Medicine, vol. iv., pp. 236, London, 1897. Robinson, Byron : A Classification of Diseases which may Belong to the Domain of the Sympathetic Nerves. Kansas City Med. Index, 1897, xviii., p. 317. Rolleston: Brit. Med Journ., i., 1895, p. 630 et seg. Romberg, M. H. : Manual of the Diseases of the Nervous System. Transl. by Sieveking, London, 1853, vol. i., p. 128. Schapiro, H. : Zur Lehre von der zuckerlosen Harnruhr, in Zeitschr. f . klin. Med., vol. viii., 1884. Thompson, W. G. : A Study of Addison's Disease and of the Adrenals. Transactions Assn. of American Physicians, vol. viii., 1893, p. 352. White, William Hale : Journ. of Physiology, x., 1889, p. 341. Ziegler, E. : A Text-book of Special Pathological Anatomy. Trans. and edited by McAlister and CatteiL London, 1896, p. 475. SEMINAL INCONTINENCE. etc. See Sexual Organs, Male, SEMINAL STAINS, MEDICO-LEGAL EXAMINATION OF. — This examination is often of great importance in connection with cases of alleged rape or sodomy. The substances which are usually submitted to the expert to be examined for seminal stains are articles of bedding or of underclothing of the supposed victim, but it often happens that other substances are also to be examined. Seminal fluid, after it has become dried, adheres very tena- ciously to any substance with which it was in contact when fresh, so that it sometimes happens that specimens of hair or scrapings from the skin require to be submitted for expert examination. In some cases it is also neces- sary to examine scrapings from the mucous membrane of the supposed victim taken in some cases during life, and in other cases, where a homicide also has been com- mitted, after death. Therefore it often happens that the stain examined is not a simple but a compound one. This stain may consist of pure dried seminal fluid, or it may be an admixture of seminal fluid with blood, pus, or cells from various mucous membranes, or of all combined.' As a general rule, a dried seminal stain upon white cloth does not cause much change in the general appear- ance of the cloth. It may be slightly tinged, or in rare instances it may be slightly bloody. Upon unstarched cotton or linen cloth it will generally be noticed, how- ever, that the cloth has a stiffer feel than the same cloth in the neighborhood of the stain, and, if it be held up to the light, it will be seen that the meshes of the cloth are filled up to a greater extent than those in the cloth sur- rounding the stain. If seminal fluid happens to fall on a non-absorbent surface, such as starched cloth, and heavy woollen fabrics as in cases of certain articles of outer clothing, or upon the skin or hair, and dries, the stain forms a nearly white deposit upon the fabric. This white stain would be very readily perceptible upon dark clothing. Up to within a few years no chemical test was known which could be applied to a seminal stain, but in 1897 Dr. Florence, of Lyons," proposed a new test applicable to human seminal stains, which he considered to be a positive test for human seminal fluid. According to the experience of the writer, it always does produce a posi- tive reaction with human seminal fluid, whether dried or 112 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Seminal Incontinence. Senega. fresh, but it also gives the same reaction with certain ' other substances. It is, therefore, like the guaiacum test for blood stains, an extremely valuable preliminary test for seminal stains, because, if a negative result is ob- tained, we know immediately that the stain in question does not contain dried seminal fluid. The reagent recommended by Dr. Florence is a solution of iodine in iodide Of potassium, made as follows: Pure potassium iodide, 1.65 gm. ; iodine (previously washed), 2.54 gm. ; distilled water, 30 gm. The test is performed in the following manner : If the stain is on a non -absorbent surface, so that it forms a layer of more or less thickness, a minute fragment can be scraped off with a penknife and transferred to a micro- scope slide, treated with a drop of water, and then a mi- nute drop of the reagent brought in contact with the edge of the drop of the water containing the fragment of the dried stain. If the stain contains dried seminal fluid, there will be formed a brownish precipitate, which, when covered with a cover-glass and examined with the microscope, will be seen to consist of numerous minute brown crystals, often arranged in groups, somewhat re- sembling the so-called hsemin or blood crystals. If the stain is upon a piece of unstarched cotton or linen cloth, the same result is obtained if a minute fibre of the cloth is cut out', treated with water in the same manner as above described, and brought in contact with a small drop of the Florence reagent. Dr. Florence, in his original article (" Du Sperme et des Taches de Sperme en Medecine Legale," Lyons, 1897), states that he has been unable to obtain this reaction with anything but human seminal fluid. He has not obtained it with the seminal fluid of any animal, nor with any other human secretion except seminal fluid, but the writer has obtained the same crystals by the action of this reagent upon a little extract of partly decomposed suprarenal cap- sule, and also with a minute quantity of lecithin treated with water. It does not give the reaction with any of the ordinary human secretions, so that this reagent is of exceptional value as a preliminary chemical test for sem- inal stains. A seminal stain can, however, be detected with abso- lutely certainty only by the recognition of the character- istic formed elements of seminal fluid, called sperma- tozoa, by microscopic examination, and generally it is necessary to use the higher powers of the microscope. These are usually found associated with various cellular elements coming from the seminal passages and prostatic ducts. Spermatozoa are usually recognized by their pe- culiar tadpole shape, having a peculiar conical-shaped head, and a long tail several times longer than the head. The spermatozoa of different animals vary somewhat in their size, and in the proportion of the head and tail. Human spermatozoa when fresh are about -^ to -g^g inch in length, the length of the head being about ^jVs inch. If seen upon its side, the head of a spermatozoon appears pear-shaped, the anterior one-third of the head being less dense than the posterior two-thirds, so that if a stained spermatozoon be examined it will be seen that the anterior one-third of the head is colored less deeply than the posterior two-thirds. Spermatozoa may be de- tected in dried seminal stains for many years after the stain was made. The writer has been able to detect them in a dried stain more than four years old. Roussin has detected them after eighteen years (Annates d' Hygiene, 1867, i., 152). Unfortunately, however, after spermato- zoa become dried, they are very brittle, and the tail is very liable to be broken off from the head by ordinary manipulation of the cloth or by the manipulation neces- sary in preparing the stain for microscopic examination. It is for this reason that so few perfect spermatozoa are found in the examination of a dried seminal stain. For the certain recognition of a seminal stain it is, in the opinion of the writer, necessary to find absolutely perfect spermatozoa with head and tail complete, since many other substances, such as certain spores, might be mistaken for the heads of spermatozoa, and many other substances, such as delicate fibrils from the cloth fibres, Vol. VII.— 8 might be mistaken for the detached tails. Care should always be taken, therefore, not unnecessarily to handle or rub the stain suspected to be a dried seminal stain be- fore submitting it to the expert for microscopic examina- tion. The recognition of the spermatozoa is comparatively easy in cases in which the stain is a scaly one upon a non-absorbent surface. In that case it is necessary only to scrape off a little of the scaly stain and transfer to a microscopic slide, treat it with a drop of water or some fluid which does not dry readily, such as dilute glycerin, or a solution of potassium acetate, and allow it to soak for several hours. It can then be gently broken up and stained, if desired, by some of the ordinary stains used in pathological work, covered with a cover-glass, and examined with the microscope. Dr. Florence recom- mends a concentrated aqueous solution of crocein, but the writer has had very satisfactory results by staining with methyl green or eosin. Usually, however, the spermatozoa can be recognized very satisfactorily if they have not been stained. A microscopic power of seven hundred or seven hundred and fifty diameters should be employed for the microscopic examination, and in some cases it will be found advisable to use an oil-immersion lens for the examination. If the stain is upon unstarched cotton or linen cloth, the recognition of the spermatozoa is much more difficult, because they are much more liable to become broken by preliminary handling, and also because the spermatozoa apparently cling very tightly to the fibres of the cloth when fresh, and are very liable to become broken when the fibrils of any individual fibre are separated. ' In order to prepare such a stain for examination, care should be taken to select a point near the centre of the stain, be- cause the spermatozoa are more apt to be present in the centre of the stain than near the edges. Then a few threads may be cut from this portion of the stain, so that the individual fibres do not exceed in length one-sixteenth or one-eighth of an inch. Each thread should then be treated separately upon a glass slide or cover-glass with a small drop of water for at least two hours, care being taken to prevent the evaporation of the water. It would perhaps be better if they could be soaked for from twelve to twenty -four hours without being allowed to become dry. These individual threads, after having been digested for several hours, should be very carefully separated into their individual elements or fibrils by means of very sharp-pointed needles. The preparation can then be stained or not, according to the desire of the examiner, be covered with a cover-glass, sealed with paraffin so as to prevent evaporation, and examined with the micro- scope. Moist material, such as scrapings from the mucous membrane of the vagina, for instance, can be treated with a drop of water and examined immediately with the mi- croscope with or without being stained. EdwardS. Wood. SENEGA, U. S. P. (Senegas Badix B. P.).— The dried root of Polygala Senega L. (fam. Polygalacece). The sen- ega plant is a smooth, perennial herb, its habit well dis- played in the accompanying illustration. Flowers small, pinkish-white, in terminal spikes; calyx irregular, of three small green, and two (lateral) large, petaloid sepals, the latter concave and enclosing the corolla; corolla con- sisting of three partly united petals, of which the lower is concave and ornamented with a crest of papillse ; sta- mens eight, diadelphous (4 + 4) ; ovary transversely two- celled; style single. Senega has a wide range in the United States, from Western New England and the Mid- dle and "Western States southward. It is now mostly- collected in Minnesota and Manitoba. The variety lati- folia is a larger form with broader leaves. The plant takes its common name, " Seneca snakeroot," from the Seneca Indians, by whom it is reported to have been used as a remedy for snake-bites. The root is mostly 7 to 15 cm. (3 to 6 in.) long and 4 to 8 mm. (£ to i in.) thick, exclusive of the large, knotty, 113 Senility. Senility. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. many-headed crown, occasionally reaching several times this size ; tortuous, tapering, and bearing several similar horizontal branches, and few rootlets, and for a variable distance below the crown a more or less sharp keel, vary- Fig. 4184.— Senega, Boot and Stem. One-half natural size. (Baillon.) ing greatly in prominence, and usually taking a spiral direction, often nearly absent ; externally yellow-brown to dark-gray -brown, longitudinally wrinkled; fracture rather tough, but short and sharp, the bark thick, yellow or brownish, of a waxy or resinous, faintly fine-radiate appearance, enclosing a yellowish-white wood, from which a larger or smaller radial segment is usually want- ing ; odor slight, disagreeable ; taste sweetish, then acrid. Various adulterants of senega have been reported, con- sisting chiefly of the roots of other species of Polygala of the Southern United States, but any other than the genu- ine root is now scarcely seen in commerce. Constituents. — The important constituents of senega are the- two saponin-like glucosides senegin and poly- galic acid, from one to two per cent, of the former and about five per cent, of the latter. There are also pres- ent from six to nine per cent, of fixed oil, some glucose, resin, gum, and very variable amounts of methyl salicy- late and methyl valerianate, which latter give to the drug its characteristic odor. Starch is wanting. Sene- gin resembles in properties and action the saponin of soap-bark, while polygalic acid resembles quillajic acid, but they are weaker, respectively, than these substances. Action and Use. — Senega possesses in medium degree the characteristic physiological properties of the sa.ponin- containing group of drugs. In the nares it is sternuta- tory, in the mouth acrid and somewhat sialagogue. In small doses it is stomachic and laxative ; in larger ones emetic or purgative. It is a nauseating yet stimulant expectorant, and this constitutes the basis of its princi- pal use. It has been extensively employed in chronic bronciiitis and other diseases accompanied by cough. As an ingredient of cough preparations it has probably its most extensive use, but is much less valued than for- merly. As an emmenagogue and diuretic it is obsolete. The dose of senega is about 1 gm. (gr. xv.). The offi- cial preparations are the fluid extract and from it the twenty-per-cent. syrup, which also contains one-half per cent, of ammonia water. The compound syrup of squill contains eight per cent, of fluid extract of senega. Henry H. Rusby. SENILITY. — (Latin senilis, from senex, an old man.) Senility is the condition of body and mind resulting from the sum total of degenerative changes characteristic of old age. The period of old age has its beginning, from the bio- logical point of view, at the time of cessation or decline of the reproductive function. This occurs suddenly in women at the time of the menopause, while in men there is a gradual decline from about the fortieth year. Some animals have no old age, as is the case with those insects that die from exhaustion or shock immediately after com- pleting their reproductive functions. Other animals, notably man, have a considerable period of old age in their lives, unless they are cut short earlier by accident or disease. During this period, which has been studied chiefly in man, the body undergoes certain degenerative changes which result in the gradual loss of function in the vari- ous organs until, if no other cause intervenes, the indi- vidual dies, as we say, of old age. One of the most characteristic features of senility, as was pointed out by Canstatt (1839), is the fact that it does not appear in all the organs of the body at the same time, but it begins sometimes in one organ, sometimes in another, while the remaining organs of the body continue in a normal condition. Of the various pathological conditions met with in the aged, it is not easy to determine always which should be regarded as strictly senile and which are more character- istic of the period of maturity. But it seems to be the general opinion that the most important and characteris- tic of the senile changes are those that occur in the walls of the blood-vessels, especially the arteries ; and, accord- ing to Demange (1886), the impairment of nutrition thus brought about is responsible for all the other strictly senile conditions. In five hundred carefully made autop- sies on old people Demange found in every case evidence of endarteritis. The importance of arteriosclerosis as a cause of lesions of the tissues appears to have been recog- nized first by Gull and Sutton in 1871. In regard to this disease Osier says: "Longevity is a vascular question, and lias been well expressed in the axiom that ' a man is only as old as his arteries. ' To a majority of men death comes primarily or secondarily through this portal. The onset of what may be called physiological arteriosclerosis depends, in the first place, upon the quality of arterial tissue (vital rubber) which the individual has inherited, and secondarily upon the amount of wear and tear to which he has subjected it. That the former plays the most important r61e is shown in the cases in which arte- riosclerosis sets in early in life in individuals in whom none of the recognized etiological factors can be found. Entire families sometimes show this tendency to early arteriosclerosis, a tendency which cannot be explained in 114 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Senility. Senility. any other -way than that in the make-up of the machine bad material was used for the tubing." As causes of wear and tear of the arteries Osier enu- merates: (1) Chronic intoxications, as from alcohol, lead, gout, and syphilis ; (3) overeating ; (3) overwork of the muscles ; and (4) renal disease. It may be too much to say that senility is always asso- ciated with or caused by a diseased condition of the arter- ies, for, according to Schrotter, the literature contains a number of cases of persons who have lived over a hun- dred years and whose arteries were found to be normal. Unfortunately, these cases have never been gathered to- gether and discussed collectively. So we know practi- cally nothing of senility from which arteriosclerosis is absent. It is interesting to note that according to the statistics of Eppinger, quoted by Schrotter, the period of maximum frequency of this disease is for men between the ages of sixty and seventy years and for women be- tween seventy and eighty years, thus corresponding fairly well with the period of maximum death rate for aged men and women, respectively. (See Longevity.) ' Councilman (1891) distinguishes three forms of arterio- sclerosis: (1) Nodular arteriosclerosis, (2) senile endar- teritis; and (3) diffuse arteriosclerosis. While these forms grade into one another more or less, the third form is regarded by Councilman as a definite disease arising during middle life, and is of little interest in connection with the subject of this article. But the other forms are so characteristic of old age and appear to play so impor- tant a part in fixing the natural limit to man's life, that they possess a unique biological as well as medical in- terest. The histological picture of these conditions is described elsewhere (see article Blood-Tessels, Pathological Anatomy of), and we will refer here only verj' briefly to their causation. The most generally accepted theory is that of Thoma, set forth in a long series of papers, the last of which appeared in 1898. According to this view, the begin- ning of the process is a "compensatory endarteritis." Thoma's law, as quoted by Peabody (1891), is that " every slowing of the blood current in the arteries and veins of man which is not completely and at once reme- died by a proportionate contraction of the media, leads to a new growth of connective tissue in the intima, which narrows the lumen of the affected vessel and thus restores the normal swiftness of the blood current more or less completely." The first cause, according to Thoma, ap- pears to be the slowing of the blood current, which may be due to a stoppage of the flow beyond or to a decrease of pressure. If the muscular coat is not able to contract sufficiently to restore the normal rapidity of current, the slowing of it in some way stimulates the nerve endings, Pacinian bodies, in the arterial wall, and this sets up a reflex hyperemia of the vasa vasorum, which in turn results in proliferation of connective tissue and an accom- panying proliferation of the vasa vasorum themselves into the media, which normally lacks these vessels. Ac- cording to Councilman, this explanation is extremely hypothetical and without analogy in pathology. Henri Martin and Huchard have developed an attrac- tive theory of the etiology of arteriosclerosis, starting with a primary lesion in the vasa vasorum. But, then, the lesion in the vasa vasorum is left to be accounted for, and there is the further difficulty, as pointed out by Schrotter, that arteriosclerosis occurs in arteries that have no vasa vasorum. Sokoloff (1892) has shown experimentally that it is not a lessening but an increase of blood pressure that causes new formation of connective tissue. And this harmo- nizes with most of Thoma's results, as, for example, thickening of the intima of the aorta between the duc- tus arteriosus Botalli and the umbilical arteries of children after birth, and the similar process in the arteries of am- putated limbs, in both of which cases there is a sudden rise of blood pressure due to the stoppage of the periph- eral circulation. It would simplify Thoma's law if we might make it read somewhat as follows: Whenever the intima is unduly stretched the connective tissue tends to increase, giving rise to a compensatory endarteritis. The stretching may be due to increase of blood pressure or to failure of the media under normal pressure. Such a proliferation of connective tissue under strain has its analogy in the reactions of bony tissue to stresses and strains, and might result from the direct stimulation of the cells without the establishment of a reflex arc. We are indebted to Seidel (1890) and to Councilman (1891) for convenient reviews of the senile changes in the various organs of the body. It will suffice for the pres- ent article to give little more than a list of these phases of senility, and the reader is referred for details to the articles on the special topics indicated. The nodular form of arteriosclerosis, which is found frequently in autopsies on old persons, is confined to the aorta and large arteries. " We find along the course of the vessel, which is otherwise smooth and of normal cal- ibre, elevated plaques, sometimes translucent and carti- laginous in appearance, sometimes calcified or softened. The growth is entirely within the intima, and the media at the point affected is thin and degenerated " (Council- man). This condition frequently involves the orifices into lateral branches and may descend to the valves of the heart, thus giving rise to serious functional disturb- ances. In typical cases of senile endarteritis the aorta and all the larger arteries are converted into almost rigid cal- careous tubes with walls thinner than normal. Similar conditions may be found less commonly in the veins and even in the capillaries. The heart is one of the organs most frequently impaired in old people. In cases of senile endarteritis it is fre- quently small, the condition of brown atrophy being com- mon. On the other hand, in seven out of fourteen au- topsies on such cases Councilman found a small degree of hypertrophy. The coronary arteries may become scle- rotic, and this is a potent cause of disease of the heart, the walls of which, according to Seidel, may undergo changes analogous to the atheroma of the larger arteries. All of the organs concerned in respiration are subject to senile changes. The segments of the sternum become ankylosed, the costal cartilages become ossified, the ribs change somewhat in shape, with the result that there is a loss of mobility and capacity of the chest. The chest muscles also atrophy, adhesions form in the pleurae, and, owing to atrophy of the alveolar walls, the respiratory surface is decreased, producing senile emphysema. The digestive tract is also subject to important altera- tions, especially characterized by the atrophy and degen- eration of the glands. The muscular fibres of the stom- ach and intestine lose their tone and allow of dilatation. In connection with disturbances of the circulation, the liver frequently suffers the lesions resulting from en- gorgement, atheromatous changes, sclerosis of the con- nective tissue, and reduction in size of the gland cells. The kidneys are subject to atrophy and sclerosis, and the renal arteries become atheromatous. The result is a diminution in the secretion, and the consequent retar- dation in the removal of waste products from the body adds another factor to the unfavorable environment of the component cells of the organism in old age. In the urogenital system the cessation of the repi'oduc- tive function is accompanied by loss of weight and vol- ume of the ovaries and testicles, with atrophy of the germinal cells and increase in the connective tissue. Ac- cording to Seidel, the arteries are atheromatous, but Metchnikov calls attention to the fact that degeneration of the ovarian ova and their replacement by connective tissue begins early in life and is completed before arterio- sclerosis sets in. Hypertrophy of the prostate occurs in a large number of old men (according to Seidel, in sixteen to twenty-two per cent.), and 'atrophy of that organ is also common. The muscular coat of the blad- der becomes atonous, due to fatty degeneration of the wall with passive distention. The ureters may also be- come distended, and their muscular coat may undergo fibrous degeneration. The connection of all these troubles with arteriosclerosis was first demonstrated, according to 115 Senna. Sensation. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Seidel, by the Guyon School in Paris (Lannois, 1885; Arthaud, 1885). The first change in the skin is the appearance of gray hair. The subcutaneous tissue atrophies, producing wrinkles, and the atrophy extends to the cutis. These changes are accompanied by atheromatous arteries and varicose veins. Even the apparently stable skeleton suffers extensive alterations in old age. There is in general a tendency toward calcification of the cartilages and ankylosis of the joints and sutures, while the spaces within the bones become enlarged and the compact bone becomes more spongy. But arthritis deformans does not belong in the category of senile alterations, as it appears commonly at an earlier period. Accompanying these changes, there is more or less atrophy of the muscles, sometimes with fatty infiltration. In the central nervous system there is some loss of weight and volume, often with local areas of degenera- tion ; while the meninges become thickened and adher- ent. The brain is one of the organs in which the connec- tion between the senile changes and an atheromatous condition of the vessels is most evident. "With the changes in the brain substance there appears a decline of its functions. The reflexes become slower and less intense. The organs of special sense become impaired, and there is a decadence of the intellectual and moral attributes. Recently Milhlmann (1901) lias described a deposition of fatty pigmented granules in nerve cells. This begins in the third or fourth year of life, the granules being at first scattered and later collected in a definite place in the cell. With age the number of cells showing this phenom- enon gradually increases, and the amount of the inert, pigmented, fatty material becomes larger in each cell until in old age there is but little protoplasm left, for the cells do not increase in size. Milhlmann regards this as a normal process of senile degeneration, finally ending in death. There are three principal theories as to the biological significance of senility : (1) Senility is the result of the inherent properties of protoplasm ; (2) it is not due to the inherent properties of protoplasm, but has been acquired as a normal process by the multicellular animals and plants for the good of the species ; (3) it is a pathological condition resulting from the imperfect adaptation of the organism to its surroundings. Maupas in France and Minot in this country are among the chief advocates of the first theory. They imagine the organism to receive a store of vital energy at the time of fertilization, and this energy is supposed to be dissipated gradually until, if no accident occurs, the organism dies of old age. As evidence Minot cites the results of his investigations on the growth of guinea-pigs, in which it was shown that the rate of growth diminishes from the time of birth. (See Growtli.) But it would seem that the facts could be accounted for equally well by the familiar physiological principle that with. growth the surface for the absorption of food increases in proportion to the square of the stature, while the tissues to be fed increase as the cube. Thus, other things being equal, the larger the organism the slower would be the rate of growth. The second theory is "Weismann's. According to his view, the protozoa never die of old age. But the higher organisms have been endowed with senility and natural death through natural selection, those species which are composed of the greatest proportion of young uninjured individuals being the best fitted to survive the struggle for existence with other species. This involves the idea that senility is a normal condition like growth or hun- ger, which is denied by the advocates of the third theory. Metchnikov (1899) has appeared recently among the latter with a remarkable hypothesis of phagocytosis as a cause of senile degeneration. He calls attention to the fact that the loss of the power of cell multiplication is not universal in old age, as one would expect it to be on the theory of senility being a normal process. On the contrary, the connective-tissue elements show a remark - 116 able capacity for growth. He supposes a struggle for existence to be going on continually in the body, in which the megaphagocytes are on one side and all the remain- ing cells on the other side. These megaphagocytes attempt to attack and devour everything they touch, whether living or dead. Healthy living cells can resist them, but when a cell is weakened by any cause, for ex- ample, bacterial poison, the phagocytes are successful, and, after destroying the weakened cells, they take their place and change into connective-tissue corpuscles. Un- fortunately for this hypothesis, however, there is very little observational evidence to support it. On the other hand, there is abundant evidence of the close relation between senility and a diseased condition of the walls of the blood-vessels, and Thoma's main thesis that this condition arises primarily as an adaptive modification to meet unfavorable conditions of life har- monizes well with the facts. The pathologists are agreed that with the beginning of arteriosclerosis a vicious circle is soon established, resulting in the progressive increase of the various troubles associated with that disease. If this group of pathological conditions does not form the sole feature of senility, it certainly forms the most con- spicuous one. And in the absence of any knowledge of the unknown conditions, if there be any, we should ex- pect, on the theory of chances, that these unknown con- ditions would be of the same general character as the known conditions. Spencer has defined life as "the continuous adjustment of internal relations to external relations, " and we may define senility as the progressive result of imperfect adjustment of internal relations to external relations. Robert Payne Bigelow. References. Oanstatt : Die Krankheiten des hoh. Alters und ihre Heilung, Er- langen, 1839. Charcot, J. M. : Clinical Lectures on Senile and Chronic Diseases. Trans, by W. S. Tuke, London, 1881. Councilman, W. T.: On the Relations between Arterial Disease and Tissue Changes. Trans. Assn. Amer. Phys., vol. 6, 1891, pp. 179-192. Demange : Etude clinique et anatomo-pathologique sur la vieillese, Paris, 1886. Martin, H. : Pathogenic des lesions atberomateuses des arteres. Rev. d. m^d., 1881. Metchnikov, E.: Revue de quelques travaux sur la degenerescence senile. Annee biol., vol. 3, 1899, pp. 249-267. Minot, C. S. : Senescence and Rejuvenation. Jour, of Physiol., vol. xii., 1891. Milhlmann, M. : Ueber die Ursachen des Alters, Wiesbaden, 1900. Peabody, G. L.: Relations between Arterial Disease and Visceral Changes. Trans. Assn. Amer. Phys., vol. 6, 1891, pp. 154-178. SchrOtter, L. v. : Erkrankungen der Gefasse, Wien, 1901. Seidel, A.: Diseases of Old Age. Wood's Med. and Surg. Monog.. • vol. v., 1890, pp. 629-665. SENNA, IT. S. P., B. P. (Folia Sennas, P. G.).— The dried leaflets of Cassia acutifolia De'.ile (Alexandria Senna), or of Cassia angustifolia Vahl (India Senna); fam. Legwminosce. In the United States, German, and French pharmaco- poeias, the general title covers both the principal vari- eties; in the British, the Alexandrian (Senna Alemndrina) and Tinnivelly (Senna Indica) sennas are distinguished by name ; they are always entirely distinct in the market. 1. C. acutifolia Delile is a small shrub about a meter (a yard) high. Its pod is broad, flat, coriaceous, slightly curved, rounded, and oblique at the ends, containing about half a dozen seeds This species has a wide and unknown range in Central Africa, is abundant in Nubia, Kordofan, Sennaar, etc., and is said to be found in Tim- buctoo. The leaflets are gathered twice a year by native tribes and carried to Alexandria, where they are very carefully freed from sticks, stems, stones, and other im- purities, and the broken and defective leaves separated, the different portions of leaf, even to the sittings, being marketed separately. 2. O. angustifolia Vahl. is also a small shrub, a good deal like the preceding, but it has larger flowers and larger, more numerously paired leaflets. Its pod is nar- rower and straighter than that of G. acutifolia, and con- tains about eight seeds. It is a native of Arabia, and in the wild state supplies an inferior, carelessly collected variety of senna (Arabian). It is also said to be found REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Senna. Sensation. Ii\t [■>-> Fig. 4185.— Leal and Pod of Cassia August if olia ; about natural size. The leaf is Tinnivelly senna. (Baillon.) in Somaliland. This is the species cultivated in the south of India (where it is not indigenous) as the source of Tinnivelly senna. The leaves, under cultivation, are increased in size and improved in quality. Although the Alexandrian variety brings a higher price and is generally held in higher esteem, there seem no good grounds for the idea that it is essentially differ- ent in its action from the other. Description. — Alexandria senna consists of leaflets with extremely short, stout petioles, about 2.5 cm. (1 in.) long and 1 cm. (f in.) broad, inequilaterally lan- ceolate or lance-ovate, acutely cuspidate, entire, subcoriaceous, brittle, pale-green or slightly yel- lowish- or grayish-green, sparsely and obscurely hairy, more so unders- neath, the hairs appress- ed; odor peculiar, tea- like; taste mucilaginous, tea-like, bitterish. It is frequently con- taminated with the one- nerved, thick, wrinkled, glaucous, equilateral Ar- gel leaves. India senna leaves aver- age nearly twice as long, though but little broader, are more abruptly point- ed, usually more yellow- ish, and the hairiness is even more obscure. Constituents. — As to its active constituents, senna is closely related to rhubarb, cascara sagrada, and some other laxative and cathartic drugs. Like them, its active principles appear to be the anthraquinones emodin, iso- emodin, and chrysophanic acid, all of which have been considered elsewhere, with which exist rhamnetin, a large amount of gum, a little tannin, and ordinary leaf constituents. Cathartic acid, formerly regarded as the active constituent, is apparently a mixed body, and fairly represents the properties of the drug. However, the ad- ministration of anything else than the entire drug, or a preparation of it, appears inadvisable. Action and Use. — This is one of the most satisfactory and generally useful of simple cathartics, usually empty- ing the bowels thoroughly in ten or twelve hours, with but little depression or other untoward effects, excepting a variable amount of griping ; it acts principally upon the small intestine, and the amount of effect produced can generally be pretty accurately regulated, by the dose, from the mildest laxative to a brisk cathartic. It is in universal domestic use, and is the foundation of numer- ous proprietary laxatives. By combination with salines its activity is considerably augmented; in small doses it does not readily lose its efficiency. It appears to be par- tially excreted in the milk, when taken by nursing women. Administration. — A few senna leaves chewed every day are a favorite habitual laxative with many people, who find them to act efficiently, withbut griping and without producing after-sluggishness of the bowels. One or two dozen leaves usually display some effect. In large doses (6 or 8 gm. [ 3 iss.] or more), as required for thorough action, it is apt to produce colic, unless modi- fied by aromatics or salines. A strong alcoholic extract is inert ; a watery extract, made from the residue after exhausting by alcohol, is active and much pleasanter than one made without this previous treatment. Infusion with hot water extracts the active principles and makes a good form for administration, but prolonged boiling de- stroys it, as do also mineral acids and alkalies. Bitters are said to increase its action. The official preparations are numerous and good. The Fluid Extract {Extractum Sennce Fluidum, U. S. P.), made with weak alcohol, represents the leaves weight for weight. It is not often given alone, but is eligible for mixture with other medicines. The Compound Infu- sion, Black Draught (Infmurn Senna Compositum, IT. S. P.), consists of: Senna, 6 gm. ; manna, 12 gm. ; sulphate of magnesium, 12 gm. ; fennel, bruised, 2 gm. ; boiling water, 800 c.c. Pour the boiling water upon the senna and fennel, macerate until cold, strain with expression, dissolve in the Epsom salt and manna, again strain, and add enough cold water to make the infusion measure 1,000 c.c. The syrup has a strength of twenty-five per cent, of senna, and contains a little oil of coriander to flavor. The con- fection contains ten per cent, each of senna and tamarind, sixteen , per cent, of cassia fistula, seven per cent, of prune, twelve per cent, of fig, and a little oil of coriander to flavor. It is a blackish extract-like mass of a sweetish taste, and is an appropriate remedy for chronic consti- pation, being especially useful for children, who take it readily. The compound syrup of sarsaparilla contains 1.5 per cent, of the fluid extract of senna. The com- pound liquorice powder has already been considered un- der Liquorice. Allied Products.— The leaves of a number of other species of the section of Cassia to which the official species belong, possess similar properties, though much weaker, and have been at one time or another proposed as substitutes, especially those of ft obovata Collad., widely diffused through the tropics of both hemispheres. No others, however, appear in commerce at the present day. Henry R. ~ SENSATION, DISORDERS OF.— The scope of the present article is the discussion in brief of those abnor- malities of sense perception not described under separate headings. General sensibility is the name given to the power of perception possessed by the various body tis- sues other than those of special sense. It is not, however, homogeneous in kind nor equal in degree, but varies in acuteness, in localizing power, and in other ways. Sen- sitiveness of the skin and mucous membranes is divided into that to tactile, that to painful, and that to temperature impressions. Muscular sense is an indefinite feeling, by which the weight and size of objects are appreciated or approximated; it is probably composite, the feeling of tension in the muscles being supplemented by tactile im- pressions from the skin and other tissues. Visceral sen- sibility has a varying but comparatively slight localizing value. Its appeal is largely to the subconscious psychic stratum; when visceral sensations rise to the level of consciousness, they may consist of visceral pain, local or referred, or be felt as hunger, thirst, fright, nervousness, psychic pain, anger, and so forth. These feelings are more or less indefinite, often not referred to an organ or part of the body, although at times they may be some- what localized, — as, for instance, hunger and depression as epigastric sensations, thirst as diyness in the mouth and throat. The general sense of well-being on which happiness de- pends is a form of general sensation known to us mainly by its occasional loss, or rather by a feeling of definite depression, not usually localized, though sometimes felt as a cardiac or epigastric sinking or feeling of heaviness. An allied and in some ways opposite state is nervousness, a much abused term, but one of sufficient importance to deserve careful definition and description. General sensibility, then, is a function of widely differ- ent tissues, much varied in kind, definiteness, and degree. The impact on consciousness due to sensory stimuli may give rise to intellectual or to emotional processes, the first being concepts relating to location, form, size, weight; the latter consisting of either pleasurable or painful feel- ings. Disturbances of sensation are classed as anaesthesia, — that is, diminution or loss of sensitiveness, which has been described elsewhere in these volumes ; hj'peraesthe- sia, — that is, increased sensitiveness; paresthesia, — that is, perverted sensitiveness; the different varieties of the latter are usually spoken of as paresthesia?. Variations in 11? Sensation. Sensation. REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. sensitiveness are spoken of as hyperesthesia or as pares- thesia only when they reach a marked degree and are the result of distinct morbid processes. Normal people vary widely in the acuteness of their perceptive power, both to tactile and to painful impressions ; different parts of the body vary widely in sensitiveness, and acuteness of sensibility varies much in any given individual at differ- ent times of the day and even more with changing vas- cularity and varying degrees of heat and cold. Sensa- tion present in consciousness varies almost directly in amount with expectant attention. Even the strongest stimuli may be disregarded and pass unnoticed under ex- citement or hypnotism. Although sensation in its restricted sense is a mental impression received from a part of the bodily organism by way of the afferent nerves, and is thus necessarily conscious, the disorders resulting from sensation in the broad sense cannot be so limited. Sensibility is not origi- nally conscious ; the earliest and lowest sensory elements subserve the purposes of reflex action ; they are evolved from cells capable of motion and possessed of digestive power, and develop their more acute sensory functions gradually. On about the same level are the sensory ele- ments in vaso-motor action. Both these activities are car- ried on as well without the aid of consciousness, in fact often better, and they are not initiated either volitionally or consciously. Automatic action, as a higher and later manifestation of nerve force than either of the above, is nearer to consciousness. While some automatic acts, especially in the lower animals, are organic and inborn, many of them in man originate in conscious volitional acts and are the result of education. In order to appreciate the importance of reflex and vaso-motor disturbances from derangement of the sensory mechanism, it is necessary to consider in brief the distri- bution of the sensory elements in the body. Sensory fila- ments of some kind are distributed to almost every organ and almost every tissue. Nerve filaments conveying im- pressions of pain are most abundant and active in the skin and the mucous membranes near the surface. The mucous membranes of the rectum, the tonsils,' the stom- ach, and the intestines may be cut without causing much discomfort to the patient. The same is true of the mus- cular tissue and the brain. The arteries, on the other hand, are quite sensitive ; the peritoneum and other serous surfaces, especially when inflamed, are exquisitely tender. Tactile sensibility is also much more acute and finely differentiated in the skin and superficial mucous mem- branes. Touching and wounding the internal organs, the stomach, the bladder, and so on, give only a general idea of the seat of injury. Irritants at the neck of the bladder and in the rectum give the same feelings ; pains are not distinguished as between the stomach and pan- creas, the liver and gall-bladder, often not even between the appendix and the right kidney. The obvious reason for this fact is to be found in the rarity of opportunities for observing and learning to distinguish between pains in these different organs. How much might be learned if such opportunity existed we do not know. The frequency of referred feelings from visceral irritation, as compared with the rare occurrence of the same phenomena from the skin, points to the low tactile value of visceral sense im- pressions. Such impressions may be referred from one part of the abdomen to the other, from the teeth to the scalp, and even from the intestinal organs to remote re- gions of the skin. These referred pains will be described more fully later. The main use of the sensory elements in the deeper structures is in the determining and controlling of vaso- motor and glandular action and the activity of the un- striped muscles; in other words, in carrying on the vege- tative functions of the organism. These may bo carried on very well without being brought to consciousness, and often when diseased they may be better performed if re- moved from consciousness. For instance, the reflex and automatic activity of the bladder is unimpaired in many cases of transverse and other spinal-cord lesions, cerebral control alone being lost. The peptic glands probably act largely though not entirely on direct stimulation, but the peristaltic movements of the stomach and automatic con- trol of the pylorus require the intervention of the sensory apparatus, normally apart from consciousness. The digestive and other visceral functions result in another set of changes which impinge on consciousness only incidentally, but are carried on by the intervention of the sensory system ; vaso-motor changes occur in the viscera themselves, and circulatory disturbances often follow in distant organs. It is necessary only to mention as examples the flushing of the face that accompanies the same change in the mucous lining of the stomach on the ingestion of food, the profound vaso-motor changes that often occur at the menstrual period, the faintness amount- ing to collapse that occurs with many severe abdominal diseases. In addition to, often in connection with, its activity in reflex, vaso-motor, and automatic acts, the sensory sys- tem contributes two elements to consciousness — the one emotional, the other intellectual; the skin and serous membranes furnish almost exclusively intellectual per- cepts and the single emotion of pain; the viscera and deep mucous membranes furnish almost no intellectual percepts, some pain, and probably all of the emotions. The emotional results of visceral action are common and familiar. Anger from hunger, irritability from dis- tention of the bladder, depression from constipation, ner- vousness and motor unrest from thirst are visceral reac- tions scarcely beyond the bounds of the physiologic. The emotions are, normally, visceral reactions to psychic stimuli. The psychologic side of the subject has been carefully worked out by William James in his "Psychology." His theory is, in brief, that the psychic cause sets up a physical change in the viscera, and the sensations from these in turn, perceived by the brain, constitute the emotions. For instance, a financial loss or death of a friend causes a change in the heart and vascu- lar system, the stomach, and other viscera. The feeble heart action, loss of appetite, and sense of unrest in the epigastrium are the direct results, not of an emotion fol- lowing the bad news, but of the news itself. The emo- tion is the perception of the changed visceral action, and without this the loss would be perceived intellectually but not emotionally. The jaundice of anger, the excite- ment and accelerated heart action of joy, and the nausea of disgust are similarly explained as the direct result of psychic stimuli, and the emotions are the perception of the altered visceral conditions. That the physical reaction follows directly on the psychic stimulus is often observed. A man who had never heard a rattlesnake, when walking on the prairie quite quietly, suddenly bounded out of the path, and only a moment after was aware of the rattling noise. In this case the reflex jump and accelerated heart action could have been dependent on no conscious emotion. Similarly men who have run away from battle assert that their legs carry them away before they realize what they are doing. The faster they run the more frightened they become. The contrary attitude of calmness is well known to restore confidence. James says that when a boy he examined curiously a bucketful of blood at a butchering. He had never heard of fainting at the sight of blood, had no fear or other emotion, and was much surprised when he found himself growing dizzy and fell to the ground. The sight of blood on the next occasion might cause nausea and repugnance from the renewing of the previous experience in memory. This brief statement of what may be called the visceral theory of the emotions must suffice. To be convincing it should be read in extenso. It is necessary to an under- standing of the part played in the human economy by the sensory apparatus of both the viscera and the skin. _ Increased sensitiveness to stimuli, called hyperesthe- sia, is common and is even more important than anesthe- sia as an indication of disease. Hyperesthesia which consists of a heightened power to distinguish variations in temperature or other qualities of objects is rare. Such increase of capability may be regarded as supernormal. 118 REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. Sensation. Sensation. It occurs in some sensitive and gifted individuals, but is usually not the result of disease. On the other hand, a painful reaction to what should be normally felt as touch, pressure, heat, or cold is common as either deep or super- ficial tenderness. It is one of the most important signs of disease, local or central. It is important to distinguish between deep and super- ficial tenderness, as that to deep pressure usually indi- cates local disease, while tenderness to a light touch with a blunt object like a pinhead, or to pinching up the skin, usually if not invariably in the absence of a super- ficial and obvious lesion, is tenderness referred from a dis- eased viscus. The headache due to brain tumor when associated with scalp soreness, elicited by gently pulling the hair or touching the scalp, is sometimes on the side opposite to the lesion; it has no localizing value, but indicates in- creased intracranial pressure. Headaches from visceral disease have been confused with attacks of megrim. The tenderness of megrim, associated with scotomata, hemiopia, and fortification lines,* and sometimes with aphasia, is always to deep pressure. Visceral headaches are not associated with these symptoms; tenderness in them is superficial and confined to areas which depend on the viscera involved and on the tender areas set up by the same disease in other parts of the body. The headache of hypermetropia comes on at the time of awaking in the morning ; it is due to strain from over- action of the ciliary muscle, and is a true visceral pain. It is associated with a superficial area of tenderness over and just above the eyes. The same area, the midorbital, may, however, be tender as the result of disease of the nasal mucous membrane, the stomach, the heart, or the apices of the lungs. Other eye diseases cause pain and tenderness of other regions ; glaucoma sets up pain in the temple, which is associated with nausea and vomiting, as are temporal pains from other causes ; temporal headache is often associated with gastralgia, and may be due to gastric or thoracic lesions or disease of the bicuspid teeth. Iritis causes tenderness in the f ronto-temporal and max- illary areas. Liver disease causes vertical headache, and ovarian lesions are associated with pain and tenderness in the occipital region, often together with pain over the lower dorsal region of the spine. The skin of the neck, trunk, and limbs may show hy- persesthetic patches from visceral disease, and there may or may not be with them like patches oyer the scalp, with headache. They are readily distinguished from the deep tenderness found in affections of the serous mem- branes, which is always local ; for instance, the tender- ness due to rheumatic inflammation of the joints, to peritonitis, to meningitis, is found on pressure over the affected structures; the pain of lumbago is similarly elicited ; appendicitis sets up local tenderness as well as referred pains in the left side of the abdomen and left lum- bar region. Disease of the uterus causes pain referred to the lower part of the back but does not cause headache. Ovarian and rectal diseases may cause pain down the thighs and in the feet, as well as hypersesthetic areas over the bod}' and head. The hyperesthesia of the trunk sometimes seen in tabes dorsalis has the characteristics of the referred variety of pain. The patient, over a greater or less and sometimes a varying area of skin, cannot bear the weight of cloth- ing or the slightest rubbing with a towel. This symp- tom may persist for years. The lightning pains in the legs are associated with a like soreness, which is, how- ever, much shorter-lived than the trunk anaesthesia, but which corresponds closely in its main features with the headaches referred from disease of the brain, the teeth, and other viscera. *Gowers (p. 840, second edition) says: "When a luminous spot is the first change and this expands, it may become dim in the centre. Very commonly the outer edge assumes a zigzag shape with promi- nent and re-entrant angles, like the ground plan of a fortification, and hence called 'fortification spectrum.'" Mills also uses the ex- pression " fortification lines." The mode of production of referred pains is not known. To suppose them signals from the viscus and apprehended by the receiving stations in the brain as coming from the skin leaves out of account the tender- ness, a local phenomenon, as are herpes and sympathetic inflammation. The setting up of such tender spots must be conceived of as a phenomenon analogous to the jaun- dice, indigestion, suppressed menstrual flow, and local flushings and pallors consequent on psychic shocks and associated with strong emotion. Whatever the explana- tion, they are important from the therapeutic as well as the diagnostic point of view. The frequency with which so-called osteopathic practitioners find tender spots in the back, and the fact that their removal by treatment usually gives the patient relief in spite of the persistence of organic visceral lesions make the treatment of tender spots, either local or referred, a matter worth y of attention. The distinguishing marks of local and of referred pains and hyperesthesia have been given above. A third va- riety of tenderness is important, viz. , that due to inflamma- tion of nerve trunks; such inflammation causes pain along the course of the nerve, with tenderness to deep pressure. This tenderness is due to involvement of the nervi ner- vorum in the nerve sheaths. When the skin supplied by the affected nerve is tender, it is so because the inflam- mation extends to and involves the terminal filaments and end bulbs. Thus both varieties of tenderness are local, not referred. The pain, however, caused by press- ure on sensory nerve fibres anywhere in their course is referred to their terminations in the skin. Paresthesie are of two kinds : perverted spontaneous feelings other than pain, and perverted transmissions of stimuli to the sensory centres. Of the first of these, itch- ing, ticklings, prickling and burning feelings, numbness, formication, and feelings of heat and cold are common. They may be due to disease in the peripheral nerves, in the cord, in the receiving centres in the brain, or they may be psychic. Of these, the immediate cause will usually be found in the periphery, and any other theory should be accepted with caution and only after careful exclusion of possible change in the nerve endings or small blood- vessels. Vaso-motor changes are prolific sources of par- esthesias of various kinds, and are a common accompani- ment of central disease. Again, the scleroses, cerebral and spinal, are accompanied not only by vaso-motor and tro- phic changes, but also by lesions in the peripheral nerve tissues, so that in a large proportion of cases paresthesias occurring in the course of central disease are found due to accompanying peripheral change. Most of the paresthesie will be found described among the vaso-motor, trophic, and cutaneous disorders. A curious form is the so-called allochiria, or reference of a stimulus to a corresponding spot of skin on the other side of the body. This symptom has been ftmnd in some cases of brain tumor, in sclerotic cord lesions, and in hysteria. Muscular sensibility is the power of feeling in relation with muscular acts. It enables one to appreciate the strength of action of the muscles, the position of the limbs, the extent of objects, and, in the case of the eye muscles, it helps to maintain the equilibrium of the body, and gives information in regard to the size and distance of objects. Muscular sense is not limited to sensitiveness possessed by the muscles. That the amount of force sent along the motor nerves is directly appreciated or estimated by the sending apparatus is probable, but hardly susceptible of proof. The amount of common sensibility possessed by the muscles themselves is much less than that of the ligaments, tendons, and connective tissues. The impres- sions conveyed to the brain are the sum of all the sensa- tions set up by strain and pressure in all of these tissues, as well as in the skin, and even in the blood-vessels, their rich sensory nerve supply being affected by pressure of the surrounding parts and the amount of contained blood varied by pressure and change of position. _ When an act or series of acts is once carried out as the result of a stimulus, it follows that stimulus the next time with greater ease. Such an impression stored up is 119 Sensation. Sensation. REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. a muscle memory. All muscular action not directly re- flex is the product of such memories ; automatic action is connected with memories which impinge little if at all on consciousness ; in fact, much of it is so rapid as to run before consciousness. Volitional acts are dependent on muscle memories combined with or added to memories of 'sense perception. The way in which the muscle sense contributes to voluntary acts has been well illustrated by Meynert. A finger is approached to the eye of a new-born child. A memory is stored up of the visual impression on the retina, of the tactile and painful impression when the finger touches the cornea, of the muscular movement which results by reflex. After this has been repeated a number of times, the sight of the approaching finger awakens the memory of the pain and the eye is volun- tarily closed by the intervention of muscle memory. The weight of an object is estimated by comparison of the muscle percept consequent on lifting it, with the muscle memories of other objects similarly lifted. The actions in so testing an object are characteristic. The position of the limbs is partly gauged by_ the exer- tion put forth in maintaining them in that position. The size of objects may be estimated by the position of the grasping hand and fingers, this being made possible by the muscular sense. The amount of eye strain in accom- modating and converging for near objects affects one's estimate of their distance and size. As small near ob- jects may subtend the same projection angle on the ret- ina as do large distant ones, it would be impossible to estimate their comparative distance and size if it were not for memories of similar things seen before, with the memories of the effort of the eye muscles in accommo- dating and converging for them. As distant objects re- quire practically no accommodation and convergence, one's estimate of their size is governed by any opinion which may be formed in regard to the distance and vice versa. Very distant objects, like the moon, are apt to be judged in relation with the objects seen at a small angu- lar distance from them — for instance, the objects on the horizon. When the head is moved the eye muscles by their action tend to keep the eyes directed toward the same object. The muscle percepts are in this case changed, and give the impression not of movement of the eyeballs, but of the shifting positions of the head. When body movements are violent, as on a ship or in a swing, muscular sensations may be so acute as to cause nausea and vomiting. Muscular sensibility is too complex to admit of close localization in the brain. The motor centres and parietal centres for common sensibility are probably the ones chiefly concerned. Isolated disturbances of muscular sensibility are not so common as would seem likely from the importance of the muscular sense. This is probably due to the fact, just pointed out, that it is complex in action and scattered in various parts of the nervous system. A severe and wide- spread lesion causes paralysis or general anaesthesia or both, either of which masks the loss of muscular sensibil- ity. Isolated loss of muscle sense usually shows itself in one of two ways : as loss of power to appreciate the posi- tion of the limbs, and as astereognosis, or failure to esti- mate the size, shape, and weight of objects. The former is more marked in the legs and is seen in some cases of locomotor ataxia and multiple sclerosis ; the latter is more often found in the arms and is a rare accompaniment of organic brain disease. A curious and rare muscular an- aesthesia occurs in the so-called megalopsia and micropsia. These are usually transient symptoms, occurring sud- denly in the early stages of tabes dorsalis and other scle- roses and in hysteria. Objects seem unusually large or unusually small from a failure of muscular sense in the ocular muscles. To test the integrity of the muscle sense the limbs should be given various positions, the patient's eyes be- ing closed, and he should be made to guess the degree of their flexion or extension. He should be made to esti- mate the weight of objects held in the hand; he should name and describe the shape and size of objects held with the eyes closed. Disorders of visceral sensibility have been less studied and less importance has been attached to them than to those of the skin, probably because of their vagueness and often their slight localizing value. They are, how- ever, from the psychologic and still more from the medi- cal point of view, of much greater importance. Visceral sensations may be classed, so far as our present knowledge goes, under the heads of local pain ; referred pains (already described); more general visceral sensa- tions on the border between pain and emotion, including hunger, thirst, fatigue, sexual desire, nausea, dizziness, and nervousness; emotions, either as direct visceral sen- sations, or as perceptions of visceral change from psychic causes, including fear, shame, anger, joy, exaltation, and depression or psychic pain. Local pain in visceral disease is usually dull even when very severe; it is, unlike referred pain, not associated with psychic or emotional change. Tenderness is elicited by deep pressure and may be masked by the referred ten- derness of superjacent skin. It may take on varying characters according to its location; when it is abdominal, the patient has a tendency to draw up the knees, with the apparent purpose of diminishing tension in the abdominal cavity. Hunger is the desire for food, which increases with ab- stention, but not indefinitely. It is born in large part from the physical state of the stomach, as indicated by the fact of its existence as a dyspeptic symptom. Too free secretion of hydrochloric acid or the presence of an excess of organic acids, either ingested or formed in the stomach by fermentation, may cause craving hunger with consequent over-eating. Spices and alcoholic stim- ulants have the same effect. The need of the body tissues in general for nourishment causes a feeling of weariness, not of hunger ; the appetite is sated before an appreciable amount of ingested food has reached the more distant tissues. Thirst is a sensation caused by the drying of the tis- sues. The mucous membranes of the mouth, tongue, and throat are the parts most affected. The feeling may be excited by other irritants. Hunger and thirst are occasional symptoms of organic brain disease. This fact does not prove the existence of a hunger centre or a thirst centre in the brain any more than running from danger proves the existence of a fear centre. The various mucous membranes have a cortical representation, and excitation of these sensory centres by disease has the same psychic result as that which follows the application of a stimulus to the membranes them- selves. Extreme hunger and, still more, extreme thirst may have an overwhelming effect on the nervous system. Sufferers from thirst in the dry hot air of the desert are maddened by the agony of the drying tissues, and die in delirium within a few hours, practically the victims of shock. Long-continued hunger commonly evokes dreams and hallucinations of banquets. Fatigue is a toxic symptom. Tired muscles are over- charged with sarcolactic acid, and brain work and other expenditure of nervous energy result in the accumulation of oxidized waste products ; in either case the result is a set of sensory signals, consisting of heavy aching pains in the muscles, soreness in the eyeballs, and, in the case of brain fatigue, a tired feeling, not in the brain itself but in the cerebral or cranial blood-vessels, possibly also in the meninges. Of more interest is the pseudo-fatigue of neurasthe- nia and of visceral disease. The same tissues are affected by the poisons formed as the result of fatigue and by stomach indigestion and intestinal putrefaction, by defec- tive liver action, and by poisons retained on account of imperfect elimination by diseased kidneys. The result is the same, viz. , heaviness in the limbs, aching of the eyes, throbbing and dulness in the head. These may be spon- taneous or may ensue on an amount of exertion too slight appreciably to affect a normal person. Such fatigue is 120 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Sensation. Sensation. spurious and may sometimes be overcome by exercise if the underlying disease is benefited by it. Great fatigue is the apparent cause of many of the functional and even some organic nervous diseases. Such disorders arise from fatigue in three ways : as the result of the acuteness of the feeling; by the overwhelming of the nervous structures by poisons produced from the overworked tissues; but mainly by the exhaustion of the nerve cells by severe and long-continued action. Of dis- eases produced in the two last-named ways we are not speaking, but only of those set up by fatigue as a sensa- tion. In the latter sense fatigue is on the same footing with the emotions, and, being ordinarily a weak sensa- tion, it is of not great importance in causing disease. Of much more import as sensation is sexual desire. It is, even apart from performance, accompanied by vaso-motor changes which, when excessive or perverted, give rise to widespread disturbances of the vascular sys- tem. The sexual organs proper are not alone concerned in the sexual act. Desire is influenced by complex con- siderations in which beauty and even intellectual attrac- tions play a part ; the phenomena of blushing, erethism of the lips and breasts, and the mysterious part played by the thyroid gland in sexual life all contribute to in- volve widely different functions in sensory sexual dis- orders. Sexual excitement, especially when accompanied by masturbation about the age of puberty, is likely to be attended with disastrous results. It is not alwa}'S easy to trace the relationship of cause and effect between sex- ual excitement and the psychoses. Either may be the cause, or they may intensify each other. They usually coexist with degenerative stigmata. Dementia prcecox, chorea, habit spasms, exophthalmic goitre, and even epi- 1 leptiform attacks may follow in the train of sexual ex- citement in the young apparently as the result of the effect on the sensorium and of the accompanying vaso- motor derangement. Nausea and dizziness are symptoms often associated with each other and with temporal pain. Nausea is not a stomach sensation, but is the sensation or the sensory and motor memory of the act of vomiting, together with that of the flow of saliva and trembling of the lips which precede it. With this there is often the sensation known as dizziness, coming from the semicircular canals, with possibly fulness of the cranial blood-vessels and throb- bing in the temples. Some of these phenomena may be absent, according to the cause of the nausea or of the dizziness. Pain in the temples, which so often accom- panies nausea, is usually the referred pain of liver or stomach disease, of disease of the cerebrum or cerebel- lum, or of disease of the eyes or teeth. One of the most important feelings on the border line between emotion and sensation is nervousness. This term should be dissociated from hysteric and neurasthenic symptoms in general and limited to the pathologic feel- ing of unrest consequent on physical or psychic stimuli, and leading, or tending to lead, to either purposive or spasmodic movements of the voluntary muscles. The predisposition to nervousness varies much in different people. When not produced by psychic causes it is pres- ent in consciousness usually as a distinct feeling from the arms or legs, although it may be occasionally referred to the head, back, or other parts of the body. The lesion may be a local irritant, a suppurating wound, a felon, or compression of a nerve trunk among other alterations, or the abnormal feeling may be referred from a viscus to the limbs or trunk as ordinary pains are referred. This re- ferred nervousness is common and is remarkable at times for its intensity. Patients suffering from an overloaded sigmoid flexure and rectum may suffer torments from nervousness in the legs and feet as do patients suffering from uterine or ovarian disease ; intestinal putrefaction sometimes causes a generalized nervous feeling that keeps the patient walking the floor day and night in agony. _ Of the causes of nervousness, aside from the predis- position which is always to be reckoned with, it makes little difference whether they are psychic, irritative, or toxic, so far as the symptoms are concerned. Any one of these causes is more effective in the presence of either of the other two, and, as with ordinary pains from what- ever cause, the amount of nervousness felt is much mod- ified by diversion and increased by attention. Nervous- ness is no more under the direct control of the will than is ordinary pain, but like the latter it may be more or less controlled by suggestion or affirmation. While the motor effects of nervousness are in some ways like those of ex- altation of acute mania, the underlying emotional content is entirely different, being in the one case disagreeable, in the other pleasant. Nervousness is, in fact, often asso- ciated with profound depression, especially when both states of feeling arise from visceral disease. The sensations which have just been described have an obvious emotional content; they hold a position about midway between feeling and what has been considered pure emotion ; they may be set up by purely physical or by purely psychic causes, and there is no peculiarity in the resulting feeling to mark its origin. The fact that impressions of touch and pain may have a purely psychic, and true emotion a purely physical cause, justifies the inclusion of the three kinds of sensation in the one cate- gory. The emotions of depression, of exaltation, fear, joy and the like, have the peculiarity in common that they are projected into the psychic environment. The tendency to find an object for a feeling of anger, and to attribute depression to a misfortune great or small, con- nects these emotions definitely with the realm of thought. That they really consist of the normal individual sensa- tions which come from the viscera but which are not rec- ognized as such, has already been pointed out. This fact puts them among the most important sensory mani- festations from the medical point of view. The study of emotion from visceral disease is attended with certain difficulties. Chief among these is the fact that disease of any one viscus, and even the same disease of a particular organ, so far from always causing the same .feeling, may give rise to the most varied play of emotions. Much, however, may be learned by observa- tions of such cases, and reasoning back from psychic symptoms to the disease is often possible even in the absence of definite physical indications. The lighter grades of emotional change may be called moods. These moods are of frequent occurrence in oth- erwise normal people, and apparently depend on either autotoxic or meteorologic influences, or both. The re- ferred pains of organic visceral disease are associated with well-defined changes of mood which are coincident in time with a sudden increase in the amount or intensity of the pain. These moods are depression, exaltation, suspicion, irritability, and with them there may be hallu- cinations of sight, hearing, and smell. The patient as- signs no cause for his depression ; he has no delusions with his hallucinations ; although his suspicions attach themselves to his friends and those about him, they are readily removed by simple denial of their truth. The moods have practically only an emotional content ; they come as suddenly as the pains, last for a few minutes or a few hours, and leave equally suddenly. They are, ac- cording to Head, singularly little affected by outside cir- cumstances, by cheerful society, music, and so on. Pains below the mid-dorsal segment are likely to be associated with depression ; above this, with exaltation. A more profound and lasting change in the emotional life is wrought by toxins of various kinds. An instance of this kind is the well-known irritability of a masked attack of gout. Depression from auto-intoxication may be so intense as to overshadow all other symptoms. Typical instances are furnished by patients who, follow- ing an indiscretion in diet, have a mass of sour material retained in the stomach. They may have with this marked but not intolerable depression, which is promptly relieved on emptying the stomach with a tube or by vomiting. Much more serious is the depression associ- ated with intestinal putrefaction, following acute diar- rhoea in patients in whom the poisons have been allowed to accumulate in the intestinal canal, and in putrefaction 121 Septicaemia and Pyaemia. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. from other causes. In these patients depression is ex- treme, often not associated with delusions except possibly the pardonable idea that they are going insane ; there may be with the depression a nervousness so great that the patient presents a typical picture of melancholia agitata, walking the floor in agony. Such cases are acute. A deficiency of the hydrochloric acid of the gastric juice may cause a mild chronic depression, simple, and easily improved or cured by appropriate treatment. In all of these cases it is not known where or how the poisons generated in the alimentary tract have their ef- fect. As the emotions are sensations from the viscera, and as the sensory nerve endings of the affected viscera are bathed in the poisons, it is not a remote possibility that their action may be a local one and not due to their being absorbed and in this manner producing an effect on the sensory centre. The prompt action of local remedies, stomach washings, purgation and enemas, favors this view. The prevailing emotion in consumption is moderate ex- altation. This may be heightened by the stimulus of an attack of referred pain, especially that due to disease of the upper pulmonary lobe ; disease of the lower lobes is likely to cause referred pain with attacks of depression. Uterine and ovarian disease is especially prolific of emotions, either simple depression, to which in extreme cases delusions maybe added, or exaltation amounting in some cases to mania. The most deceptive forms of these affections are those in which there are no accompanying symptoms, sensory or otherwise, calling the patient's at- tention to the affected organs. The difficulty is further increased by the fact that digestive disturbances may make their appearance and mask the other symptoms. The difficulty of distinguishing between these cases and cases of insanity with coincident visceral lesions may be considerable, as these patients possess many or all of the symptoms of insanity, and yet it is not very important to make the distinction between the two classes of cases. Organic defects should be remedied, if possible, even in the insane, and in addition it may be fairly doubted whether even in cases of hopeless insanity, organic vis- ceral disease may not often be the determining cause of the mental breakdown. The pelvic organs sag and pull on their attachments and as a result there are sent out to other parts of the ner- vous system signals of distress which take not only the form of moods, but of pains in the back and head, vaso- motor disturbances, flushing, fainting, palpitation and the like. In the same way sagging abdominal organs set up all these classes of symptoms. In especial a prolapsed kidney is often responsible for attacks of dizziness, head- aches, flushings, and faintness which are often attributed to anything but their real cause. One of the'most sticking emotional changes from vis- ceral disease is the fear suffered by patients afflicted with angina pectoris. A good deal of anxiety is felt by many patients who suffer from palpitation, over and above what would be warranted by the nature of their com- plaint. The fear in angina pectoris is inherent and does not proceed from a knowledge of the danger incident to the disease. It is a signal to the brain direct. Little more has been attempted in the present article than an outline of the subject of sensory disorders, with the idea, especially, of tracing the complex relations which exist between the sensory system of the skin and that of the viscera. Consciousness is not, in this con- nection, of prime importance. It is a mysterious light that shimmers on a few of the actions and reactions of the nervous system; in considering the part played in disease by the sensory system, it is of especial importance to recognize the fact that sensory phenomena may and often do take place without its intervention. Henry S. Upson. SEPTIC/EMIA AND PY/EMIA.-Historical Memo- randa. — A constitutional disturbance accompanying pu- trefaction in wounds, particularly fractures and injuries of the skull, was described by Hippocrates. In the Middle Ages Ambrose Pare and Paracelsus, both noted metastases following certain injuries in which suppura- tion occurred. In 1720 Boerhaave first enunciated the doctrine that the condition was due to pus in the blood. His contemporaries, Morgagni and Petit, also tried to prove that metastatic abscesses were brought about by penetration of pus into the blood. In 1774 John Hunter recognized phlebitis as an intermediate factor in produc- ing metastatic abscess, but the exact relation of the two was not clearly defined. In the early part of the nine- teenth century (1808-22) Gaspard initiated the experi- mental method of studying septicaemia by injecting pu- trefying materials into the veins of animals. Later, the investigations of Virchow, Billroth, O. Weber, Koch, and others formed the basis upon which Gussenbauer built the following definitions: "By putrid infection or septicemia we mean that general disease of the body which results from the introduction into the circulation of the products of decomposition, and which is character- ized by definite changes in the blood, a typical succes- sion of inflammatory processes, and a continuous fever together with peculiar nervous symptoms and critical discharges." Pyemia is defined by him as "a general infective disease which arises from the entrance into the blood of the constituents of infected pus, and is distin- guished from other septic infective diseases by the de- velopment of multiple pus foci in different organs, and an intermittent fever." Since Gussenbaur formulated these definitions, exten- sive investigations have been made from both a bac- teriological and a pathological standpoint. From the studies of Ogston, Rosenbach, Doyen, von Eiselsberg, and others the conclusion is drawn that the general sys- temic disease known as septicaemia depends upon the introduction of pathogenic, especially pyogenic micro-organ- isms into the general circulation. Marmorek further limits the definition of septic intoxications, infections (mycoses), and pyaemia to those general systemic diseases caused by the activity of the streptococcus pyogenes and staphylococcus aureus, for, he claims, that these are the only two micro-organisms which can cause all the various phases of septicaemia, from a carbuncle to the most severe pyaemia. He excludes as etiological factors such agents as bacterium coli, pneumococci, etc., which he claims cannot cause furunculosis, lymphangitis, and lymphadenitis. However, this cannot be accepted by the clinician, for not only are his premises and therefore his conclusions incorrect, but in addition there are so many forms of septic intoxication and infection pre- sented to the observer, in which the etiological factor is other than the streptococcus pyogenes and staphylococ- cus aureus, that it is impossible to limit the disease to those agents alone. Classification. — Konrad Brunner (" Erfahrungen und Studien liber Wundinfektion und "Wundbehandlung, III. Theil. Die Begriffe Pyamie und Septhamie im Lichte der bakteriologischen Forschungsergebnisse ") classifies the disease from an etiological and symptomatological stand- point. Slightly modified by the present writer, it is as follows: 1. Septicmmia Not due to Bacterial Activity. — A general disease brought about through necrotic or putrefactive processes. II. Systemic Diseases due to Pyogenic Microbes ; Pycemia, Acute or Chronic. — General infections in which metastases make their clinical appearance, due generally to staphylo-, strepto-, pneumo-, and gonococci, or to proteus, pyocy- aneus, coli, or typhoid bacilli ; the fundamental principle being that the signs and symptoms of metastases break in upon the general symptoms. 2. Pyotoxinmmia, Toxinmmia, Tox&mia. — A general disease without the clinical signs of metastases, but with the symptoms of a constitutional intoxication, brought about by all kinds of bacteria. III. Pyosepticmmia or Septicmmia. — A general disease in which the products of pyogenic bacterial activity combine with those of decomposition to cause the symp- toms. For a fuller discussion of the subject of classi- 122 REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. Septicaemia and Pyaemia. flcation the reader is referred to the above work by Brunner. Etiology. — So far as the classification is concerned, the bacteria, in all but the first form of the disease, play the chief role. There is no specific micro-organism, but a whole series of them as etiological factors. The same micro-organism acts differently under different conditions. There are many factors which tend to change or govern the result of their activity. The point of infection, the character of the media into which they penetrate, the personal factor, the microbic association, the varying viru- lence of the micro-organisms themselves, the lowered vitality of the parts — all these influence the course of the infection. The mode of entrance of bacteria into the system has been the subject of much investigation. In some cases they are, through the medium of a seemingly slight wound, introduced rapidly into the circulation, presuma- bly being taken up by the capillaries. In the great ma- jority of the cases, however, the bacteria first gain access to the lymph spaces and are carried through the lymph channels to the blood. Starting from a localized pus focus the bacterium first has to pass the barrier of granu- lation tissue, which has been thrown up by the tissue as a bulwark against the bacterial invasion. That healthy granulation tissue does act as a successful barrier has been conclusively demonstrated by Noetzel in his experiments on sheep. When these granulations, however, are not sufficiently developed, the micro-organisms pass through them and enter the lymph spaces. By the lymph they are carried to the lymph nodes, which present the next barrier against their invasion. In their course to the nodes varying degrees of lymphangitis may be set up. The nodes increase in size and in some way, as yet not definitely known, they retard the growth of the bacteria and in niany cases limit their further growth. Dr. Mal- lory, of the Harvard Medical School, has lately demon- strated that in the periphery of the node there sometimes occurs a proliferation of the endothelial cells lining the trabecular which traverser the lymph spaces. These take upon themselves phagocytic properties and enclose not only the bacteria but also leucocytes themselves, which may already have ingested some bacteria and in addition large numbers of red blood cells. In the nodes the pyogenic bacteria often bring about suppurative proc- esses and, destroying these organs, pass on and are emp- tied into the blood stream. More often the resistance of the nodes is overcome without producing suppuration. Upon reaching the blood the bacteria are again attacked. Through the production of so-called sozins and alexins (the mode of origin of which is unknown) the growth of the bacteria is again hindered ;' in fact, these sozins and alexins, aided by the leucocytes acting as phagocytes (Metschnikoff), may destroy the bacteria. Canon believes that the chief difference between septicaemia (pyotoxi- nsemia) and pyaemia depends upon the phenomena, that in septicaemia the bacteria increase and produce their toxins in the blood, whereas in pyaemia the bacteria are introduced into the blood but do not increase there. Brunner holds that there never occurs any marked growth of bacteria in human blood, and he thinks that this is one reason why bacterial blood tests sometimes fail. An acute mycosis is met with in no human infection. He further holds that the micro-organisms are especially prone to collect in the parenchymatous organs, and in the acute cases they set up metastatic processes, which, however, remain microscopically small, the duration of the disease being too short to develop macroscopic foci or to be clinically evident. The bacteria carried by the blood may be deposited in the various tissues and organs of the body and there continue their activity and bring about local inflamma- tory or suppurative processes. They may, on the other hand, be destroyed in the tissues and be excreted. The relation of thrombophlebitis to the blood will be dis- cussed later. All authors hold that in the majority of the cases the ordinary pyogenic cocci, i.e., the pyogenic staphylococci and streptococci, alone or associated together, constitute the cause of the disease. The streptococci have long been looked upon as liable to bring about more virulent infections than the staphy- lococci. But no absolute line can be drawn. We may have an acute or a chronic streptococcus infection with or without metastases. The same is true of the staphy- lococci. However, many other bacteria play an impor- tant part, etiologically, in this disease. The pneumococcus may cause a metastatic-pyaemia, or a pneumococcus- toxaemia, in which the bacteria are found in the blood. Metastatic foci occur most frequently in the meninges and the joints. The B. coli communis generally invades the system from the intestinal tract. Cholecystitis, ab- scess of the liver, peritonitis are often sequelae. Cys- titis is set up, the bacillus being carried by the lymph vessels or the blood. Meningitis, pneumonia, strumitis, etc., have followed its escape into the blood. It has also been isolated in local phlegmon and lymphangitis. The gonococcus is frequently met with in pyaemic conditions. B. typhosus, B. pyocyaneus, B. Friedlander, Proteus vul- garis, Micrococcus tetragenus, and many others are capable of bringing about the disease. The infection may be a mixed one, a double infection taking place at the same time, or a secondary infection taking place in a focus already the seat of microbic activity. It often happens that only one of the bacteria can be demonstrated in the blood, and when streptococci and staphylococci are associated, the streptococcus is gen- erally the one to bring about the general infection. Pathology. — In the mildest form of the disease, septi- caemia witliout bacterial activity, or, as it is more commonly termed, " sapraimia," the pathological changes are limited to the site of the necrosing or putrefying focus. In the pyosepticcBmic form of the disease we have locally the combined phenomena of pus formation and putrefying, decomposing, or necrosing tissue. It may exist in the form of a moist gangrene. Often, in the case of wounds which seem at first insignificant, but in which cases there ensues a malignant and rapidly fatal toxaemia, the patho- logical findings are very slight. More often we have the local changes of a pyogenic disturbance, presenting all of the characteristics of local inflammation and abscess formation. The primary focus may be a carbuncle, an infected wound, an otitis media, an osteomyelitis, a gas- troenteritis, a pneumonia, etc. From the seat of infec- tion the inflammation spreads, the lymphangitis is set up, the nodes are attacked, and lymphadenitis follows. The bacteria . reach the blood and here many changes occur. Sozins and alexins are produced, and antitoxins are elaborated. Ewing holds that the bacteria are pres- ent in the circulating blood only for short periods and at infrequent intervals, and that a few hours before death various bacteria, some of which may not be active in the original process, make their way into the circula- tion. There is a rapid development of severe anaemia. The red blood cells are diminished in number, and in the more severe cases a slight poikilocytosis and degenera- tion of the cells occur. Sometimes normoblasts appear. Grawitz reports a case of acute septic infection, in which after two days the red blood cells were reduced to 300,- 000 per cubic millimetre. The blood plaques are in- creased. Leucocy tosis is marked, except in the very mild and very severe cases. Changes in the blood-vessels occur mostly in relation to the local pus foci, but often by means of mural inplantation the endocardium is attacked and ulcerative or malignant endocarditis ensues. When a vein in the neighborhood of an abscess is attacked the adventitia is the first to be affected. The ordinary phenomena of inflammation follow, and the other coats of the vein become involved. The intima becomes swollen and inflamed and fibrin is deposited on it, which becomes t.he nucleus of a coagulum. This in- creases until the lumen of the vein is occluded and a thrombophlebitis established. Sometimes the thrombus extends for a considerable distance along the vein. As the infective process advances from the primary focus, the microbes invade the thrombus and there bring about 123 Septicaemia and Pyaemia. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. purulent softening of the mass. Before this occurs small particles of the thrombus may be broken off, and, enter- ing the general circulation as emboli, find lodgment in the various organs. In this way infarcts are produced, and these in turn may become infected by the bacteria in the circulating blood, thus giving rise to metastatic pus foci. In the original thrombus the process of purulent softening goes on, and if not checked by local forces or by treatment the whole mass breaks down and the parti- cles laden with micro-organisms follow the course of the embolus and lodge in the portion of the vascular system where the size of the vessel retards its progress. Post-Mortbm Findings.— In pyotoxinamda and pyosep- ticmmia putrefaction develops rapidly. In the subacute and chronic cases the original wound is found to be foul and unhealthy in appearance. The lungs may show congestion and oedema ; small pleural and pericar- dial effusions are frequently seen. There is a marked degree of gastro-enteritis, the inflammation affecting es- pecially the lower bowel; generally cloudy swelling of the spleen, liver, and kidneys is present; the nervous system is not much affected; bacteria may be demon- strated in the connective tissues; the lymph nodes are enlarged. In the rapidly fatal peritoneal pyotoxirwmias the gut is found greatly distended with gas ; the perito- neum is grayish and lustreless, and shows a fine network of congested vessels. In pymmia the wound looks gangrenous. The adjacent veins are thrombosed. Metastatic abscesses are seen, most often in the lungs, liver, spleen, and kidney. The intes- tinal tract is not so often affected. The brain may show a passive hyperemia but metastatic foci are rare. In the joints there may be either serous or purulent effusions. Heart lesions are not frequent, but they do occur. When recovery takes place, there is a gradual regenera- tion, the bacteria disappearing from the blood and the local conditions subsiding. Signs and Symptoms. — The complex of objective signs and subjective symptoms of the disease in its various forms vary to such an extent that no hard-and-fast lines can be drawn. And still there are groups of symptoms which are most frequently observed in certain manifesta- tions of the disease. Under the division of septicamia without bacterial activ- ity are included all those conditions in which from a specific focus of necrosis or putrefaction or decomposi- tion the toxic elements elaborated by these processes are absorbed into the general circulation and thereby bring about a general poisoning of the system. The primary focus may become infected, and so, through the addition of the bacterial element, we have a pyosepticasniia, to be described later. Septicaemia without bacterial activity — or, as it is more commonly termed, " sapraemia " — is most strikingly exemplified in the so : called ptomai'n poisoning, which originates in the gastro-intestinal tract, and in the cases of retained secundines, in which the putrefactive changes take place in the placental tissues and without bacterial activity bring about a general poisoning. The tyrotoxicon discovered by Vaughan, of the University of Michigan, is accepted as the etiological factor in the poi- soning from cheese, and is supposed to be the active principle in some of the other forms of ptomai'n poison- ing. Large masses of gangrenous or sloughing tissues which are confined within the body may bring about the dis- ease. The symptoms which develop are those of a poi : son which is gradually progressive, acting as a depressant on the nervous system, and bringing about a considerable febrile movement. The disease affects more especially the gastro-intestinal tract. There is no chill to mark its onset. The patient has a persistent headache, general malaise, anorexia. At first there is only a slight rise of temperature ; the pulse frequency is increased ; there is some nausea. If the cause is not removed the headache becomes more intense, the temperature rises, vomiting takes place, and diarrhoea is the rule. The blood shows degenerative changes, diminution in the number of the red blood cells, decrease in the haemoglobin index, and some leucocytosis. These changes vary with the intensity of the poison. In the fatal cases the temperature is con- tinuously high, the pulse rapid and feeble, delirium fol- lows restlessness, coma develops, and death occurs. In the cases which originate in the intestines the most marked symptom is the violent vomiting and purging, which may even simulate cholera. Most of this class of cases of septicaemia react well to treatment, and when the cause is removed there is a rapid return to normal conditions. In pyotoxinmmia attention is first called to the local conditions. It may be a suppurating Wound which is draining poorly, an unopened abscess, or some deeply seated inflammation. In the cryptogenic form (i.e., that form in which the original focus of infection cannot be found) there may be a history of some old trouble which is supposed to have subsided. A gastro-enteritis, a pneu- monia, a cystitis, or a perityphlitis may be the starting- point. The patient at first does not appear to be very ill; there is some prostration; he complains of a slight headache which does not yield to treatment ; the appe- tite is poor: no interest is taken in surroundings; the symptoms of lymphangitis and lymphadenitis may be present; the temperature shoots up, especially in the evening, with only slight morning remissions; the pulse becomes rapid ; the patient feels " feverish " ; there may be some pain in the wound. Often an examination of the local condition will demonstrate the cause of the symp- toms, and prompt surgical treatment may cut short the further course of the disease, the condition returning rap- idly to normal upon removal of the local cause. If the disease goes on, gastro-enteritis appears, with vomiting and diarrhoea. The tongue, at first thickly coated, be- comes dry and hard. The heart's action becomes weaker and increasingly rapid, often out of proportion to the tem- perature; the arterial tension is lowered, and in the severe cases cyanosis appears. The liver and spleen are often enlarged. The urine shows albumin and casts. The skin may show a slight yellow tinge, but icterus is not so marked here as in pyaemia, and is probably due to de- structive processes in the blood-rather than to hepatic dis- ease. At first dry and hot, the surface of the body later is bathed in perspiration, the skin feeling cold and cada- veric. The prostration increases, the expression is list- less, the face being drawn and colorless, the eyes are sunken, and the alae nasi dilated ; no complaints are heard. If the disease reacts to treatment, a general improvement of the sensorium is first noted ; the pulse becomes a little stronger although still rapid ; the temperature gradually subsides, often showing at first marked morning remis- sions, until finally the evening rise disappears; the desire for food gradually returns ; the heart is the last entirely to recover its normal condition. The disease may run a chronic course, lasting for from three to twelve weeks. The temperature in these cases is not generally high, but is often quite irregular. The spleen is frequently pal- pably enlarged, this being simply a phase of the general lymphatic enlargement. If, however, recovery does not occur, the condition may rapidly become worse, the tem- perature continuing high and the heart rapidly failing. Finally, violent purging, anuria, delirium and coma, are likely to precede the patient's death. In the malig- nant cases the course may be very rapid, presenting possibly only a slight lymphangitis, an increasingly high temperature, rapid cardiac failure, rapid overwhelming of the nervous system, and death. This last form is occasionally seen in cases of wounds received at the post- mortem table, cases in which, from a seemingly slight wound, the most intense and rapidly fatal toxaemia de- velops. In typical cases of pymmia, in which multiple abscesses are produced as a result of infected emboli, the clinical picture is somewhat different. The conditions at the primary focus may be the same as in pyotoxaemia. Severe local injuries, wounds of the joints, compound fractures, injuries of the veins, fracture of the skull, associated with pyogenic processes, are the most frequent among the primary lesions in pyaemia. The local con- dition may not appear to be especially active, but is 124 REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. Septicaemia and Pyaemia. markedly persistent. The wound looks bad and exudes a semi-serous, foul-smelling pus; and the surrounding tissues become oedematous and deeply inflamed. The temperature is not very high, with moderate morning remissions, and the pulse is rapid. This may continue for about a week, during which time the induration does not lessen, but extends more deeply into the tissues. Suddenly, on the tenth or twelfth day, the patient has a severe chill, following which there are a burning fever and then a profuse perspiration. Again, the wound may have been doing very nicely, and the evidence of infec- tion may have been slight, when suddenly a chill ap- pears and pyaemia is ushered in. Such chills are gen- erally a reliable index of the lodgment of an embolus in some portion of the vascular system. The chill may, however, be very slight, and in those forms of pyaemia in which the secondary foci are caused through direct in- fection by the bacteria circulating in the blood, and not by infected emboli, often no chill at all appears. In pyotoxincemia and pyoseptiewmia a chill rarely is noted. Chilly sensations sometimes occur, but a sudden, violent chill is the exception. Following the sweating there is marked exhaustion. The temperature immediately preceding or during the chill is likely to shoot up to the highest point of the curve only to drop in a few hours, but not to normal. The chill may be repeated the same day or on the next day. The temperature runs apace, and describes a very irregular tracing, varying from hour to hour. The sensorium is perfectly clear, and the patient exhibits none of those somnolescent feat- ures which are seen in an acute toxsemia or pyosepticaemia, but he is keenly sensible to his suffering. The local symp- toms of the new foci soon make their appearance. Pain is felt in the chest or under the border of the ribs, and upon examination an abscess of the liver, a pleurisy, or a pneu- monia is found. The joints may be swollen and tender. Icterus is generally seen, slight at first but often marked in the later stages of the disease when the emaciation is far advanced. There is not so much gastro-enteritis as in toxaemia, and, in fact, in the earlier stages the constitu- tional symptoms are very little in evidence. The tem- perature continues as before, possibly not so high, exhib- iting, however, the same marked irregularity. The tongue, at first thickly coated, becomes later dry and hard and looks dirty. The-patients are often hy peraesthetic and suffer much from local pain. They often complain of pain first in one place and then in another, and sometimes there is a general sensitiveness all over the body. The cause may possibly be referred to localization of bacteria in the tissues, where they set up inflammatory process- es and, in many cases, purulent collections. Later, the patients lose all sensation of discomfort. Erythematous and sometimes pustular eruptions appear on the skin. The pulse, which at first was fairly strong but rapid, later becomes weak and rapid. At any time the local symp- tom of some new metastatic focus may be ushered in. Prostration is very marked, the emaciation is severe. Gradually the patient becomes unconscious and dies in a comatose condition. In puerperal pyaemia, the course is very similar. In the chronic form of pyaemia chills are much less frequent and recovery may occur. Von Leube (" Specielle Diagnose der inneren Krank- heiten ") states that from a scientific standpoint it is not always possible at the bedside to differentiate between the two conditions septicaemia (meaning toxaemia, pyo- septicsemia, etc.) and pyaemia, or, better, strictly to draw the lines between these forms. The one leads into the other, and many cases of pyotoxinaemia would develop into pyaemia were it not for the short duration of the dis- ease Therefore he holds that in most cases it is proper to speak of a septicopyemia. This is the form, he main- tains, which is most likely to occur in the cryptogenic type of the disease. The patient, sometimes in fine health, sometimes suffering from a slight illness, begins to have pain in the legs, loss of appetite, eventually headache, vomiting, then a severe fever, and is very ill. The fever, often like a fluctuating typhoid, may be, how- ever, continuously high, with slight remissions. The ten- dency is markedly to an up-and-down course, with irreg- ularly intercurrent chills. The pulse in the severe cases is very rapid, varying from 130 to 150, soft, dicrotic, and sometimes irregular, especially so in cases' in which, on post-mortem examination, the heart walls are found to be the seat of metastatic abscesses. The heart is dilated, and endocarditis very frequently occurs. At times the endocarditis is the only objective sign of the disease at first (a loud systolic or systolic-diastolic murmur, in- creased second pulmonic sound, etc.). This cardiac con- dition governs very markedly the course of the disease. Embolic processes in the spleen and kidney follow, and abscesses form. This is the condition commonly termed "malignant endocarditis," but von Leube believes that the so-called malignant endocarditis is really a crypto- genic septicopyaemia, in which the septic poisons become localized in their action on the endocardium and remain circumscribed for a long time here. In the majority of cases, however, the endocarditis is only a link in the great chain of multiple inflammatory foci. Next in diagnostic importance comes the inflammation of the joints, which may occur as an involvement of a single joint, or many joints may be affected at the same time. In such cases the disease will very closely resemble acute articular rheumatism. The process concentrates itself most often in one joint, which becomes greatly swollen. In connection with this we often have bone in- volvement, which, however, may take place independ- ently of the joint inflammation. The long bones are es- pecially susceptible. The foci may be circumscribed or be extensive in their involvement of the bone tissues, and they may present the ordinary symptoms of osteomye- litis. Changes in the skin are almost constant. Rose- ola, erythema-like urticaria, purpuric spots, hemorrhagic pemphigus, blisters, pustules, herpes, etc., are among the most frequent of its manifestations. As the disease ad- vances these cutaneous inflammations may extend into the underlying tissues and large areas of inflammation and oedema, or haemato-purulent infiltrations, may be found. These affections, especially the hemorrhagic forms, are met with in three-fourths of the cases of " cryptogenic septicopyaemia, " and are therefore important signs from the standpoint of differential diagnosis. Symptoms ref- erable to the nervous system are quite constant; head- ache, vertigo, sleeplessness, delirium, convulsions, and temporary paralysis are chief among these. When me- tastases develop, purulent meningitis, abscesses of the brain with their various symptoms, are among the possi- bilities. Retinal hemorrhages are occasionally seen. Through localization of the septic processes on the pericardium, pleura, and peritoneum there ensue at times small areas of inflammation, or serous or purulent exu- dations, with their symptoms. In the lungs miliary abscesses are found, or in other cases large infarcts, abscesses, lobular pneumonia; especially frequent is a diffuse bronchitis. Cyanosis and increased respiratory movements are brought about by the heart weakness and pulmonary complications. The spleen is no more enlarged in this form than in the others. But metastatic abscesses in the spleen and liver may increase the size of these organs very markedly. The symptoms referable to the digestive tract are neither constant nor characteristic. Icterus is only occasionally seen. The kidney functions are almost always affected. Albumin in the urine is the rule, and is caused by the septic irritation of the renal parenchyma. Acute ne- phritis, with its characteristic symptoms, often follows. Large abscesses may be formed, but as a rule there exist multiple miliary, sanguino-purulent collections in the kidney tissue. Besame. — Here we have, then, a form of the disease, put down by von Leube under the name of " cryptogenic septicopyaemia, characterized by the following symp- toms : A very pronounced, irregular fever with a dispro- portionately high pulse frequence, great emaciation, more or less marked nervous disorders, enlargement of spleen, 125 Septicaemia and Pyaemia, REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. and special symptoms referable to the various organs in which the septic poisons become localized. In brief, then, the disease is one in which a peculiar form of exanthema develops, and in which the inflammation of the joints, the muscle and bone tenderness, the endocarditis, the embolic processes in the spleen, liver, lungs, and brain, the nephritis, the inflammation of the serous membranes, ' the petechial hemorrhages, all play a part in making up the complex of symptoms. Grawitz (" Klinische Pathologie des Blutes, " 1902), in discussing this form of septic poisoning, states that in most cases of " cryptogenic septicopyemia " pyogenic bacteria are present in the blood, and that in many un- certain cases a positive diagnosis may be established by a blood examination. A negative result, however, does not exclude the disease. He further maintains that in cases of ulcerative or malignant endocarditis repeated failure to isolate the micro-organisms from the blood speaks most strongly against the disease being present, and vice versa. In the cases of pyosepticcmnia the symptoms vary somewhat, and are very largely governed by the patho- logical conditions which give rise to the disease. In gangrene of the lung, in tuberculous coxitis which has be- come secondarily infected, in chronic myelitis and myelitis transversa, in which decubitus, necroses, etc., are asso- ciated with poly -infections, we have striking examples of a pyosepticaemia. These processes, when examined bacteriologically, are found most often to harbor many different varieties of micro-organisms acting together. The streptococci, bacillus coli communis, proteus vul- garis, and bacillus pyocyaneus are frequently found associated in such a process. The symptoms then are those of the local condition and the general poisoning of the system. The fever is marked and the pulse rate is high and, as in the other forms of septic poisoning, the spleen is enlarged. The temperature is very irregular and of the remittent type. The nervous system is mark- edly involved, more so than in the pyotoxinremic forms. The blood itself does not show such marked changes, and frequently micro-organisms cannot be demonstrated in the general circulation. We have then in these cases to deal with a condition of poisoning, due chiefly to the absorption of the toxic products from a localized process, rather than with disease resulting from a bacterial in- vasion of the whole system. The symptoms in cases of septic intoxications and in- fections, as given above, are only composite pictures of the various forms of the disease. In many of the actual cases the disease manifests itself differently, and the course of these cases can be best demonstrated by giving examples of actual cases. The following cases, unless otherwise designated, have been taken from the records of the Methodist Episcopal Hospital of Brooklyn, New York. Case 1, Pyotoxinwmia Following Infection of Knee- Joint.— On June 20th, 1888, an operation was done on the knee-joint to remove a foreign body. The next day there were considerable pain in the joint and tenderness. Temperature rose to 100.6° F., pulse 110, respirations 25. Second day after operation pain continued, the tempera- ture jumped to 104° F., pulse 148, and patient felt listless. Third day : Patient began to vomit, at first at intervals of two or three hours and later in the day almost con- tinuously, temperature remaining high and pulse becom- ing irregular and rapid. Some diarrhoea. Fourth day : Vomiting not so marked ; bowels moving involuntarily ; patient very restless. Temperature continuously above 102° F., pulse averaged 138, respirations 28. Fifth day: Joint re-opened and small amount of sero-sanguineous fluid was evacuated. Irrigated with antiseptic solutions and thoroughly drained ; no change in general condition. Sixth day: Patient delirious, the bowels still moving frequently, temperature and pulse continuously high. Eighth day: Still delirious; much diarrhoea. Patient lies in a sort of stupor, twitching of muscles of the left shoulder and fingers of right hand ; marked flushing of left side of face. Slight paralysis of the left facial mus- 126 cles. Picking at bedclothes. Temperature had fallen to 100° F. , pulse 120. Perspired freely. Under treatment, by thorough drainage and irrigation with antiseptic solutions, these symptoms gradually abated with the exception that the temperature remained continuously above 100° F., and the pulse about 100. On the thirtieth day the joint was again opened and some dead bone re- moved, after which the wound healed, the temperature becoming normal and the pulse dropping to 90. The patient had entirely recovered after an illness lasting over two and one-half months. In the accompanying chart are shown the temperature and pulse curves for the first sixteen days of the disease. CLINICAL CHART. Namp, Hispasp, Date..... DAYS OF MONTH I I | DAYS OF DISEASE \f z 3 4 a 6 f 8 9 10\?1 7& /d\/-4 / % -j J V, _J 1 X ) f "1 i 1 fc 3-A / 1 *v > , 7 0T j / A . «o V k<* t l J \ V A * ) / i i * ' j [ I 1 i 1 1 i 1 i i / / *i 7* / , . «-* f /• I FIG. 4186. This is an example of a case of pyotoxinsemia arising from an infection in the knee-joint. Infection of this joint is an event always to be dreaded by the surgeon, for in almost all such cases a rapid and often fatal tox- aemia, and frequently a pyaemia, occurs. The synovial membranes of the joints offer very little resistance to the inroads of bacteria, and when once affected are easily destroyed and the process attacks the underlying tissues. It has been shown that streptococci may be introduced under the skin of an animal and there set up only a local- ized abscess, but the same organism when injected into the synovia of the knee-joint will bring about a virulent and rapidly fatal intoxication. In the present case, no bacterial examination was made. The infection evi- dently took place during the operation, and although the condition was soon discovered and thorough drainage established, still the process persisted for over two months. During the course of the disease the tempera- ture and pulse were continuously high, with intercurrent remissions. The point of special interest in this case is the peculiar involvement of the nervous system, which showed itself in the unilateral paralysis of the facial muscles, the twitching of certain sets of muscles, and the flushing of one side of the face. Case II. Cryptogenic Pyotoxincemia.— Patient had been in poor health for about a year. Two weeks previous to admission had a severe chill, followed by fever and REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. Septicaemia and Pyaemia. sweating. Chills occurred on successive days thereafter. In a few days patient began to complain of great pain in gluteal region, and then in knee and ankle. At end of eight days there were marked swelling, pain, and tender- ness of the left knee and ankle. This continued, and on admission to hospital the temperature was 103° P., pulse 120. Under local treatment inflamed condition of ankle subsided, but knee remained swollen and tender. May 19th : Knee-joint was opened and considerable pus evacu- ated. Drained. During the ten days following the oper- ation the temperature abated somewhat, but the pulse remained continuously high. Patient in a semi-stupor. June 1st: Patient passed into a "typhoid state," tempera- ture becoming irregular again. June 3d : A necrotic spot appeared on left buttock. "Wound looks more healthy. June 6th: Severe chill, following which temperature reached 103° F. and pulse 140. Necrotic spot on buttock broken down and surface granulating slowly. During next six days temperature at no time high, but irregular. Pulse vacillating between 120 and 170, very weak and irregular. Frequent diarrhceal movements. June 12th: Death. Autopsy showed only inflammatory condition in and around knee-joint; cloudy swelling of kidneys; fatty degeneration of liver. Spleen was soft and normal in The question arises in this case as to how the bacteria gained entrance to the joints. The autopsy does not help us in deciding this. There were no other foci of inflammation and no history of any wound as a starting- point. It therefore comes under the head of cryptogenic pyotoxinsemia, the main point of suppuration being, as in the previous case, in the knee-joint. There evidently was also an inflammatory process in the gluteal region and in the ankle, but these were controlled. There had been no pneumonitis, otitis media, enteritis, or urethritis to attract our attention. The initial symptoms, repeated chills, and high temperature, followed later by pain in the gluteal region, knee, and ankle, would suggest em- bolic pyaemia. But this we cannot have without some initial lesion. The origin then remains a mystery, crypto- genic. In this case there was no enlargement of the spleen. Case III. Staphylococcus Pyotoxinommia with Transi- tion to Pyamia. — February 19th, 1888 : Patient fell down- stairs, sustaining an injury to left ankle. No external wound. February 28th entered hospital complaining of pain in and around ankle-joint, which was somewhat swollen, tender, and red over a circumscribed area. No fracture could be demonstrated under chloroform. Pain increased in spite of local applications, and on March 2d patient had a temperature of 103° F. There were slight remissions of the continuously high temperature. Pa- tient's general condition poor, pulse 110 to 120 per min- ute. March 5th: Very restless and during night slightly delirious. Area of redness extended slowly. March 6th : Fluctuation appeared at ankle. Incision was made and considerable pus was evacuated. Bone not involved. Following the operation there was a slight fall -in the temperature, which, however, rose again the next day to above 103° F. March 7th : Temperature still high, respirations very rapid and superficial, but examination of the lungs was negative. Over the cardiac region, most distinctly over the aortic area, were heard a distinct friction sound and a blowing murmur, where previously 'there had been none. In the evening this friction sound disappeared. During the night the patient became very restless, and toward morning began to vomit at long intervals. Temperature reached 104.5° F., pulse increas- ingly rapid, 130 to 160. There was marked emaciation. Vomiting became more frequent, bowels moving involun- tarily. Gradually the patient became comatose, pulse imperceptible. Death. Autopsy : Pericardium injected and the sac distended with pale, greenish-yellow fluid and flocculi of fibrin. No fluid in either pleural cavity. Lungs in places adher- ent. Heart is covered with a layer of fibrin, thicker in some places than in others ; fibrin also seen on the peri- cardium. Left lung: Scattered through the lung are areas of congestion surrounding infiltrated patches with whitish centres ; none of these areas is larger than a pea. Right lung : On surface, especially on anterior border, are a number of small circumscribed white spots, cone-shaped upon section. On posterior surface are a number of small punctate spots of hemorrhage. The lung is some- what cedematous and congested ; bronchi are normal. Heart muscle is very pale. Spleen enlarged and soft.- Right kidney : Just beneath the capsule is a single small abscess. Microscopical examination : The nodules described in the lungs and kidney proved to be small infarcts, the blood-vessels leading to them being occluded by firm thrombi. They consist of masses of inflammatory tissue with small pus collections. Bacteriological Examination : Original wound, infarc- tions of kidney and lungs, showed pure culture of staphy- lococcus pyogenes aureus. Diagnosis : Acute pericarditis, multiple infarctions of both lungs, abscess of kidney. Staphylococcus pyo- toxinsemia passing into pyaemia. Remarks: We have here the history of an injury, to the ankle-joint without any external wound being present. The staphylococci may have gained entrance through the skin which was evidently bruised, although no actual open wound occurred. Again, the micro-organisms may have been conveyed to the joint by the blood from some other undiscovered focus. The only clinical evidence of pyaemia was noticed on March 7th, when a pericardial friction sound was heard. There were no chills, but there were marked gastro-intestinal symptoms, a continu- ous remittent fever, and a weak but rapid heart's action — in fact, all the clinical symptoms of a pyotoxinsemia, which at autopsy proved to be an embolic pyaemia. Case IV. Pyosepticamia. — November 8th: Patient on admission to hospital presented an area, over right eye, about three inches in diameter, bright red in color, with a well-defined margin, slightly cedematous and gan- grenous in places. It was covered with small sup- purating points. Upper eyelid enormously swollen. Temperature 106 ° F., pulse 120, respirations 35. Opera- tion: Curetting of necrotic tis- free incisions. November Temperature dropped to F., pulse 75, respirations Patient delirious, tinnitus aurium. Extensive reddish, pa- pular eruption on chest. Skin cold and clammy. Later in day, temperature rose to 104° F., pulse 110; vomiting. November 10th : Diseased area shows the char- acteristics of a sloughing phagedsena. November 11th : Restlessness and delirium alter- nating with stupor. Great pros- tration. Temperature continu- ously high. The phagedena spread rapidly and involved a large portion of the head. Pa- tient died in coma. A glance at the accompanying chart (Fig. 4187) will show the remarkable deviation in the temperature and pulse curves. The disease, originating in an inflammatory condition of the face, developed into a virulent phagedena, combining a sup- purative and a putrefactive process, which resulted in a rap- idly fatal intoxication and in- fection of the entire system. It therefore falls into the class of pyoseptiemmia. However, most cases which may be classified as fig. 4187. sue, 9th: 95.6 25. Name,.- DAYS OF MONTH *1 DAYS OF DISEASE t Z d 4- 01 a. $ a. in a. s 14 l- UI CD _J 0. 107° 106° 105° 104° 103° 102° 101° 100° 99° NORM. TEMP. 98° 97° 96° 95 150 140 130 120 110 100 90 80 70 60 'I M E M E M E ~ 7 A • i/ \ I f A i ^ t i 127 Septicemia and Pyaemia. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. pyosepticaemia run a more subacute or chronic course. The following case reported by Brunner (loc. cit., p. 101) is an excellent example of this, and his analysis of the same is of interest: Diagnosis: Chronic myelitis; decubitus sacralis. Pu- trid abscess of thigh. Polyinfection by streptococci, bacillus pyocyaneus, bacterium coli, proteus vulgaris. Death. Pyosepticsemia. History: Patient well until three years ago. First signs of disease appeared as feeling of fatigue in the feet, chilly sensations and formication. The symptoms were steadily progressive. Disturbance in the function of the bladder and rectum appeared, and finally loss of control of same. In December complete loss of use of the legs ; later, decubitus sacralis. Admitted to hospital January 25th, 1898. Status prceserts (at time of admission) : Both legs useless. Hardly any sensation in them. Beginning involvement of upper extremities. Involuntary micturition and de- fecation. Decubitus spots, about size of silver quarter of a dollar, on each heel. Over the sacrum a deep de- cubitus about the size of the palm of the hand ; sacrum exposed, a further defect over the lumbar vertebrae and over the trochanters. High temperature. Urine cloudy, strongly ammoniacal. Course: February 13th: The decubitus slowly enlarg- ing. Application of vinum camphoratum. In the region of the left trochanter a collection of foul-smelling pus, undermining the skin. February 19th: Always high temperature with morning remissions (see accompanying chart, Fig. 4188). On right thigh a large fluctuating «,_. abscess has formed. ' ' ' Incision and drainage. A large amount of filthy, bad - smelling material and gas evac- uated. During the night exitus letlialis. Autopsy: Ten hours after death. Extract from the protocol. On back, over the sacrum and over the trochan- ters, the above - de- scribed decubitus de- fects. The abscess cavity on the right thigh reaches from the patella to the middle of thigh ; its periphery presents masses of bad- smelling necrotic tis- sue, with threads of fascia running through it. A sound can be passed from this ab- scess cavity up to glu- teal region. Spleen very much enlarged and soft. Both kid- neys contain small ab- scesses, the size of a pea. Bacteriological Ex- amination. — I. During life: 1. Examiuation of urine : bacterium coli. 2. Examination of blood. February 19th : Blood aspirated from vein of arm, under aseptic conditions. Cultures made on glycerin-agar and in gelatin. Result negative. 3. Examination of pus evacuated from ab- scess cavity at time of incision. Smear examination; streptococci in short chains, numerous small rod-shaped bacteria. In the glycerin-agar and gelatin cultures, copi- ous growth of pure culture of proteus vulgaris. Patho- genesis: Injection of 1 c.c. of original culture into ear vein of rabbit, evening of February 24th, caused death during night of February 25th. Guinea-pig: Injection DAYS OF MONTH 1 1 1 DAYS OF DISEASE 72 73 141S\16\17 id w III <£ 3 r- < ui 0. 2 111 H UJ 3 n. 107° 106° 105° 104° 103° 102° 101° 100° 99° NCMM. TEMP. 98° 97° 96° 95 150 140 130 120 110 100 90 80 70 60 M E M E M £ M E M E HI E U E M £ — X r-» \ A f t r V V s V \l A / i V \r J u \ ft / ^ I* £ i I i c FIG. 4188. of 1 c.c. of the same culture subcutaneously into wall of abdomen on February 24th, 4 p.m. February 27th, local infection. February 28th, fluctuation. March 1st, incision and thick yellow pus evacuated! Culture on agar showed proteus in pure culture. Injection of 1 c.c. of the same growth into abdominal cavity of guinea- pig. Animal lived. II. At the autopsy: 1. From the deepest portion of the decubitus; proteus vulgaris greatly predominating ; Bacterium coli and bacillus pyocyaneus also present. 2. Thigh abscess : proteus vulgaris. 3. Heart blood: pure culture, of proteus vulgaris. 4. Liver : proteus vulgaris. 5. Spleen: negative. 6. Kidney abscess — could not be properly examined owing to use of non-sterilized knife in making the section. Analysis of the case by Dr. Brunner. Avenue of the infection. On account of the myelitis the trophic changes and anaesthesia of the skin took place, and owing to pressure the mortification of the tissues occurred and pressure-necrosis resulted. Owing to incontinence of urine and faeces the area became easily infected with the proteus vulgaris and bacterium coli, to which later was added the bacillus pyocyaneus. The B. coli caused early a cystitis. Subcutaneously the tissue surrounding the sacral decubitus broke down under the attack of the pyogenic micro-organisms. The process worked down along the thigh and manifested itself there in the forma- tion of a putrid, gas-containing abscess. In this abscess the proteus vulgaris was the most active agent, and was found in pure culture in the remotest portions of the cavity. Streptococci were found only in smear prepara- tions and could not be demonstrated in the cultures. It is probable that they were active during the abscess for- mation up to the time when the incision was made, but were no longer able to develop or were killed by the pro- teus in the culture media. From this extensive area of putrefaction with destruction of much tissue, the poisons which were elaborated were doubtless absorbed into the blood. It is also very probable that from time to time various streptococci and proteus rods wandered into the blood stream; they, however, did not develop in the blood ; a bacterisemia — bacterial septicaemia, in the sense of Koch's definition — was not present. That such a con- dition did not exist at the height of the disease is proven by the negative result in the examination of a relatively large amount (5 c.c.) of the blood. The bacterisemia post mortem was in itself not proof positive. Characteristics of the Clinical Picture. If one may ever speak of a " rotten infection " and " putrid intoxi- cation," this case certainly falls into such a class. Put- refaction and malodorous decomposition were brought about through the activity of four dangerous micro- organisms: streptococcus, bacterium coli, proteus vul- garis, and the bacillus pyocyaneus. Together with this disintegration occur the pyogenic phenomena due to these germs. A large gas abscess developed, and this, together with the decubitus, was the chief source of the poison which brought about the general intoxication. High fever, high pulse frequence, dry tongue, enlarge- ment of the spleen, changes referable to the nervous sys- tem — these are the symptoms of the intoxication. The temperature curve again shows the zigzag remittent type without special diagnostic significance. An intense in- vasion of the circulation by the causative agents, or any growth of the same in the blood, did not occur. Bac- teriremia is excluded, and a toxaemia remains. Since we have in this case a combination of pus formation and putrefaction, it falls into the class of pyosepticsemia. The small abscesses in the kidneys are explained as an extension of the B. coli infection from the bladder. In the absence of a bacteriological examination a definite conclusion cannot be arrived at. The gonococcus starting from an initial lesion in the urethra may act alone or in combination with other micro-organisms to bring about a general infection or pyasmia. Bujwid, in his article, "Gonococcus als die Ursache pyamischer Abscesse" (Centralblattfur Bakteri- 1895, Bd. xviii.. S. 435), presents the following 128 REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. Septicaemia and Pyaemia. case : Young man, thirty-two years of age, suffering from chronic gonorrheal urethritis, after passage of a sound had a severe chill -which lasted some time. This was repeated the next day and the two or three days follow- ing. Later, four abscesses appeared : one in the region of the left shoulder, one in the right popliteal space, one on the inner side of the left leg, and one over the external malleolus of the right leg. These abscesses were all con- fined to the muscular tissues and did not involve the Connective tissue or the joints. Upon incision they con- tained a small amount of odorless, brownish red pus, in which the gonococcus in pure culture was found. Ohmann reports a case in which the complications were multiple arthritis and tendo- vaginitis, epididymitis, and nephritis, and in which case he was able to demon- strate the gonococcus in the blood. Brunner states that in these cases the course may be very acute with all kinds of complications, but that there is very little ten- dency to destruction of tissue. Finger, from his observa- tions in gonococcus pyaemia, holds that in such inflam- mations there is always a tendency toward the early formation of granulation tissue and later an increased con nective-1 issue formation. There occur in the urethra strictures; in the prostate a destruction of the glandular structure; in the epididymis, thickening of its walls; in the joints, ankylosis etc. The micro-organism is less energetic and less destructive in its action than are the other pyogenic agents. In the cases of puerperal infection, owing to the richness of the blood and lymph supply incident to preg- nancy, the disease is often very rapid and fatal. It may follow the type of a pyotoxinoemia, a pyosepticaeinia, or lastly a pyaemia. In the rapidly fatal cases pyotoxi- naemia is most frequent, while pyaemia is often a compli- cation. In the subacute cases pyosepticsemia is often the form of the disease which is present, the uterus and adnexa being found in a necrotic or gangrenous state associated with pus formation. Otitis media frequently is the starting-point of a gen- eral septic infection, the sigmoid sinus becoming in- volved and thrombo-phlebitis resulting. Purulent men- ingitis and abscess of the brain with their characteristic symptoms may cause death, or a typical embolic pya:mia with metastatic foci in the lungs, heart, kidneys, etc., may develop. The course is generally long. Prognosis. — In septicaemia without bacterial activity the prognosis depends mostly upon the etiological fac- tors and the ability to remove the cause. When the condition is due to retained sccundines, the removal of the same is followed by rapid recovery. In the various formsof ptomai'n poisoning, from the ingestion of putrid foods, some prove rapidly fatal, while others recover upon removing the offending material from the intesti- nal tract. But, in general, the adoption of prompt treat- ment, as soon as the cause is discovered, is followed by recovery. In the milder forms of pyntoxinmmia and pyosepti- casmia the disease often is amenable to treatment, but all forms depend upon many factors. The age of the pa- tient, the ability of the tissues to check the inroads of the bacteria, the virulence of the micro-organism, the site of the infection have all been referred to above. Even in the severe cases, the establishment of thorough antiseptic treatment may bring about recovery. In gen- eral the prognosis is poor. In the majority of cases of pyosepticsemia the prognosis is bad. The prognosis in pyaemia is always grave. When metastases develop rapidly and involve important organs the result is usually death. In gonorrhoeal pyiemia the prognosis is better. Warren ("Surgical Pathology," p. 378) claims that there is a relatively high percentage of cures in puerperal pyaemia. Diagnosis. — To distinguish between the different forms of the disease from a clinical standpoint is often im- possible. It must be remembered too that one form may merge into an advanced form without any marked symp- toms to designate the period of transition. In septicaemia without bacterial activity surgical interference with dis- Vol. VII.— 9 appearance of the symptoms will establish the diagnosis. In the cryptogenic or spontaneous forms of the disease a careful examination of the entire body must be made and all of the secretions be carefully tested. The pres- ence of a suppurating focus, lymphangitis, enlarged regional lymph nodes, with a continuously high tem- perature, very rapid pulse, absence of chills, indifference of the patient, gastro-enteritis, presence of albumin and bacteria in the urine, and bacteriaemia would point most strongly to pyotoxinaemia. Such conditions as a gan- grene of the lungs, moist gangrene of the extremities or other portions of the body, extensive decubitus and other necrotic and putrefactive processes in which pyogenic bacteria are present, and accompanied by a markedly irregular temperature, rapid and feeble pulse, pronounced nervous disorders, no marked blood changes, and nega- tive bacterial blood tests, together with the other phenom- ena of septic intoxication, may be safely diagnosed as pyosepticsemia. If, in the presence of an imperfectly draining wound, cellulitis, lymphangitis, thrombo-phle- bitis, ulcerative endocarditis, pyosepticaemia, pyotoxi- memia, or any of the conditions above mentioned, there occurs a sudden sharp chill, accompanied by a marked rise in temperature, and followed by sweating and pain referred to some distant point, pyaemia must be sus- pected. If, in the subsequent course of the disease, the chills are repeated, the mental faculties remain clear, marked emaciation, hyperaesthesia, diaphoresis, and great prostration are present, and the symptoms of metastatic abscesses make their appearance, the diagnosis of pyae- mia is definitely established. Among the diseases which resemble the various forms of toxaemia, septic intoxications, and septic infections, may be noted acute articular rheumatism, malaria, typhoid fever, acute miliary tuberculosis, severe anaemias, and uraemia. But in each case a careful inspection of the history and a thorough consideration of the signs and symptoms which each disease presents will result in a correct differential diagnosis. Theatment. — Prophylactic. — The state of our knowl- edge at the present day enables us to operate almost without fear of infection, and a thorough understanding of the aseptic treatment of wounds is presupposed by the writer. It is, however, to be especially emphasized in the preparations for any operation on the knee-joint. Chronic tuberculous processes, wherever they may be, especially those of the joints and bones, are most fre- quently confined to the points of their primary activity and do not generally give rise to a systemic intoxication; but if, during the course of an operation upon such a process, it becomes secondarily infected the condition be- comes much more serious, and any of the forms of intoxi- cation or infection may develop. This must also be borne in mind in the treatment of any infected wound, for a polyinfection is generally more difficult to handle than a monoinfection. In the various nervous diseases in which trophic disturbances are present, much care must, be exercisec. to prevent bedsores. If a decubitus should appear despite the frequent change of position, rubbing with alcohol, etc., they should be treated aDti- septically, to prevent if possible any infection. The prophylactic measures in the treatment of compound fractures, extensive lacerated and contused wounds, and burns, should always be carried out most carefully. Locnl Treatment. — Tn the cases of septicaemia without bacterial activity the results of removing the cause are very marked and satisfactory. If the offending sub- stance be contained within the intestines, a course of calomel in divided doses, followed later by a saline purge, may be all that is needed to bring about recovery. In the puerperal cases the removal of the sccundines, the lingers being used as a curette and the scraping being followed by a hot saline irrigation, is indicated. The same principle is to he followed in all of its forms, i.e., the cause must be removed under all possible aseptic pre- cautions. In the other forms of the disease the care of a pus focus must first be considered. If the case presents itself 129 Septicaemia, Serum Diagnosis. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. with an abscess already formed, the indication is_ to evacuate the pus. Ubi pus, ibi evacua. If a putrefying area is associated with a purulent focus, as mueh as pos- sible of the putrid material should be cut away, the sur- geon being careful not to expose healthy surfaces. In such a condition it may be proper to swab out the cavity* with pure carbolic acid and then immediately after to cleanse it with alcohol. All such abscess cavities should be irrigated with some antiseptic solution and thoroughly drained, at first with iodoform gauze and later by means of rubber-tube drains. In cases in which, following an operation, there develop the symptoms of toxaemia, an early inspection of the wound should be made, and if in- fection has taken place the sutures should be removed, the wound irrigated with some antiseptic solution, drain- age established, and dressings wet with some non-irritat- ing solution, as Thiersch's solution of boracic and sali- cylic acids, be applied. The wound should be dressed daily or, in the virulent cases, more often. In some cases constant irrigation is indicated. In pyaemia, where possible, the secondary foci should be opened and treated as above. General Treatment. — The routine treatment always in- cludes as a preliminary procedure the stimulation of all of the excretory organs. The bowels should be freely moved, the kidneys stimulated, and diaphoresis increased. The proper nourishment of the patient should be carefully looked after, easily digested food being given in small amounts, and, when the stomach is unable to retain food, rectal enemata of peptonized milk, peptonized egg, and whiskey should be given every four hours, in amounts not exceeding from four to six ounces. The hygiene of the sick-room is also of importance ; every opportunity for fresh air, sunlight, and cheerful surroundings is to be favored. In no condition is careful nursing more necessary. The use of drugs is not very satisfactory. Antipyretics are contraindicated, for they often act as powerful cardiac depressants and mask the symptoms. Alcohol in the form of egg-nogs, whiskey, and brandy, is ' considered by many to have very beneficial effects. In fact, these patients bear large amounts of alcohol very well, and it should be given freely. The heart's action can be stimulated best by using relatively large doses of the tincture of digitalis. If the diarrhoea is troublesome, it may be controlled by opium, or by bismuth and salicylic acid in their various forms. Paresis of the gastro-intes- tinal tract may be treated by an hypodermic injection of atropine sulphate gr. / T , and bisulphate of quinine gr. v., to be repeated in five hours if necessary. The use of intravenous and subcutaneous infusions of normal salt solution acts very beneficially in these cases. It helps to maintain the circulation, protects the nervous centres, dilutes the poisons, and assists very materially in the elimination of both the micro-organisms and their toxins. The infusions may be given daily in relatively large amounts, 1,000-1,800 c.c. being given intraven- ously. An objection has been raised to this, the state- ment being made that such a regular dilution of the blood would cease, after the first day or two, to have any bene- ficial effect; but this is not true, for in the course of twenty -four hours the excess of the solution may be en- tirely excreted from the body and anew infusion be called for. "With this as a basis, many experiments have been made by adding antiseptics to the solution with the hope of bringing about a direct antiseptic influence upon the micro-organisms in the circulation and tissues. Intravascular Antisepsis. — Experiments were carried out by Maguire, of London, to ascertain the effects of in- troducing a solution of formaldehyde gas directly into the circulation. His experiments were carried out upon animals and upon himself, and he concluded that 50 c.c. of a 1 to 2,000 solution of formaldehyde gas, or 50 c.c. of a 1 to 800 solution of formalin, could be safely intro- duced into the circulation without bringing about any serious blood changes. After injecting 100 c.c. of a 1 to 2,000 solution of formaldehyde into his own circulation, the only change that was noted was the appearance of :albumjn in the urine. Later, he injected 263 c.c. of a 1 to 2,000 formaldehyde solution. There followed consid- erable cramp-like pain in the arm, where the solution was injected, and peculiar cardiac distress. Many red blood corpuscles and blood-coloring matter were noted in the urine. This disappeared the next day. A solu- tion of 1 to 1,000 formaldehyde, of which 63 c.c. was in- jected, caused severe pain in the arm and faintness. Maguire's conclusions were that 50 c.c. of a 1 to 2,000 solution of formaldehyde (1 to 800 solution of formalin) was the maximum dose to be safely injected in man. That is to say, if the total quantity of blood in an adult be estimated at 5,000 c.c, the solution of formaldehyde in the blood would be 1 to 200,000, which is a very efficient germicide. Barrows, of New York, applied this principle in the successful treatment of an advanced case of puer- peral sepsis, as reported in the New York Medical Journal, January 31st, 1903. In his case he gave an intravenous infusion of 500 c.c. of a 1 to 5,000 aqueous solution of formalin, and on the third day following a second infu- sion of 750 c.c. of the same solution was given. There followed a rapid, marked, and permanent improvement which resulted in recovery. As a result of his experi- ments and those of others he concludes that the pro- cedure depends on its being correctly and scientifically applied. He warns the profession against its indiscrim- inate use where proper blood cultures have not been made. It is also suggested that normal salt solution be used in making the formalin solution, as it has been found that no change takes place in the formaldehyde in this solution. Although no harm has been done to the blood cells by the infusion of formalin in distilled water, theo- retically the normal salt solution is to be preferred. Fortesque-Brickdale, as a result of his experiments upon rabbits, published in the Lancet, January 10th, 1903, does not favor the use of intravascular antisepsis. He states: "That rabbits injected daily with non-toxic doses of oxycyanide of mercury, formic aldehyde, chino- sol, protargol, or taurocholate of sodium are not thereby protected from the usual effects of a previous inoculation of virulent anthrax ; and that chinosol and formic alde- hyde in large doses (toxic) so depress rabbits infected with the pneumococcus that they die sooner than an un- treated animal. " Credg has applied the theory of intravascular antisep- sis in the use of colloidal silver or collargol. This he claims to be a non-irritating, strongly bactericidal agent which may be employed as an inunction or as an intra- venous infusion without any detrimental effects, and which is followed by marked improvement and often by recovery from the most severe forms of septic infection. He recommends it especially in cases of general sepsis, puerperal fever, pyaemia, and septic osteomyelitis. In the less severe cases, especially where the infection is localized, he uses a fifteen-per-cent. ointment of colloidal silver, rubbing two or three grams into the skin, after mildly irritating the same and causing local hypersemia. In the more severe cases he recommends an intravenous injection of from 5 to 20 c.c. of a one-half to one-per-cent. solution, repeated daily or every week as required. Of his more recently perfected collargol solution he uses from 2 to 10 c.c. of a two-per-cent. solution. His tech- nique is as follows: The syringe should be cleansed, the silver solution, and no other chemical, being used for this purpose. The syringe is then partially filled with collargol solution, and the detached needle is inserted, either through the skin or, if necessary, but only after a carefully made preliminary dissection, into the vein. The syringe having been attached to the needle, some blood is withdrawn into the syringe in order to remove from it any bubbles that may be present. Finally, the fluid is slowly injected. Subcutaneous injections are not effective. Viett used the intravenous method in a series of twenty cases of sepsis, and recommends it strongly. The experiments of Grindes and Balardzsheff , however, do not bear out the conclusions of Crede, for they reported that a one-per-cent. solution of collargol had no effect on anthrax, staphylococcus, and streptococcus infections. They report that unless the injection is given at the 130 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Septicaemia. Serum Diagnosis. point of the inoculation of the micro-organisms, no effect followed. They claim that the simple injection of collar - gol intravenously causes death sometimes. Baginski, Naltenius, and Kunzl-Krause report no beneficial results. However, other experimenters have met with decided success in its use, and the failures of others may be due to faulty technique. Unguentum Crede, an ointment of metallic silver, has been used by some in the treatment of these cases. Forty -fi ve grains are rubbed into the skin very gradually. Antistreptococcus serum of Marmorek is limited in its usefulness to certain kinds of cases, but in these it has met with marked success. The favorable cases are those which are caused by streptococci alone, and when the in- fection is a mixed one, the serum acts upon the strepto- coccus infection alone. In many of the cases reported the disease was already far advanced, and consequently they can scarcely be considered satisfactory test cases of the usefulness of the procedure. Packard and Wilson (American Journal of the Medical Sciences, December, 1902, p. 1033) have collected 117 cases treated during the past two years with antistreptococcus serum, and in 114 of these cases there followed either temporary im- provement or prompt recovery. After citing many other cases they make the following statement: "All of these reports tend to convince us of the fact that antistrepto- coccus serum will at least do no harm, and that in cases in which the streptococcus is alone involved it will elim- inate that micro-organism and control the symptoms caused by its toxin unless used too late for any remedy to be of avail. When the streptococcus infection is found in combination with those of other micro-organisms we have learned that the serum has no influence except in so far as it controls the streptococcus symptomatology. Undoubtedly the attempt to obtain a polyvalent serum is one in the right direction, and, as in typhoid fever, it presents a key to new accomplishments in the line of special serum therapy." Special forms of treatment are indicated in infections of different regions of the body. In extensive processes involving the extremities amputation may save life, but even after such a drastic measure it may be found that the infected thrombus has extended too far to be checked, or the systemic disease may be developed to such an ex- tent that amputation is contraindicated. Klebs first sug- gested the idea of ligating and removing the veins in which thrombi had formed before the infected emboli should become broken off and pyaemia set up. This pro- cedure is especially considered in involvement of the lat- eral and sigmoid sinuses following suppuration in the middle ear. Here thrombo-phlebitis is very likely to oc- cur, and the internal jugular vein is also frequently in- volved. The first step of the operation should be in most cases the ligation of the internal jugular below the point of involvement. Then the sinus may be exposed and the purulent material scooped out or gently washed out. Sometimes an excision of a portion of the vein is indi- cated. In cases in which the pyogenic focus is in the pelvis, or in which a general suppurative peritonitis exists, the entire abdominal cavity may be flushed out with hot salt solution. The head of the patient's bed may be raised, which, as Fowler suggested, will favor gravitation of the purulent material into the pelvis, from which it may be aspirated every few hours. The question of the treatment of puerperal sepsis occu- pied the attention of the Fourth International Congress of Obstetrics and Gynaecology in Rome, September, 1902, and formed one of its chief topics for discussion. The following extracts are taken from the report by Dr. H. N. Vineberg ("American Gynaecology," January, 1903). The conclusions of H. Treub (Amsterdam) were as fol- lows: The usual methods of treatment (curettage, intra- uterine irrigations, ice bags, cold baths, turpentine injec- tions, antistreptococcus serum, alcohol) for puerperal sepsis localized in the uterus are in most cases followed by cure. In a few exceptional cases hysterectomy will be indicated. Tuffier (Paris) said that in a given case of septiccemia, post partum, or post abortum, when there is no cause for the fever to be found either in the external genitals or in other organs, when the usual methods of treatment are of no avail and when the peritoneum and adnexa are intact, and the uterus is large, flabby, and is discharging fetid lochia, and if the patient's general con- dition warrants it, total extirpation of the uterus should be done, whether there be placental retention, a slough- ing myoma, or the so-called "metritis desiccans." A. Pinard (Paris) recognized only the following indications for hysterectomy: retained putrid placental remains, sloughing myoma, and perforation of the uterus. The convalescent stage calls more for careful nursing and attention to general hygienic principles than for drugs. Nourishing food, fresh air, and cheerful sur- roundings are the essentials. Paul Monroe Pitcher. SERUM DIAGNOSIS AND SERUM THERAPY— I. Sebum Diagnosis. — Serum diagnosis and serum treat- ment rest upon the same fundamental principles. When a group of foreign cells enters an animal body, whether in the form of disease or of experimental infection, there results a group of changes both in the foreign cells and in one or more cell groups of the body which they in- vade. These changes are peculiar and specific in relation, both to the invader and to the territory invaded. The- blood, as the representative of all organs, undergoes spe- cific changes which are at the basis both of serum diag- nosis and of serum therapy. A few examples will make- this clearer. When a human body is invaded by a group of cells of that peculiar species known as typhoid bacilli, the blood acquires a number of new and specific proper- ties, specific in the sense of manifesting their action only in relation to the typhoid bacillus. Upon one of these new properties serum diagnosis is based. The ability to agglutinate any specimen of the race typhoid bacilli is possessed to a feeble degree by the blood of many healthy human beings. But when a person is or lately has been suffering from typhoid fever, the agglutinating power of the blood over typhoid bacilli becomes greatly increased, and the resulting reaction, first brought into clinical use by Widal in 1896, is that ordinarily known as the " Widal reaction. " This reaction, like all the agglutinative reac- tions, is specific in a double sense. The bacilli are thus- agglutinated only by the serum of patients recently or formerly infected with typhoid. On the other hand, no> bacillus, except the typhoid bacillus, is clumped in higb dilutions by typhoid serum. The reaction has therefore a double use. Given a group of bacilli clearly identified as typhoid, we can use them for testing the serum for diagnosis in doubtful febrile cases. Or, given some serum or blood from a case known to be typhoid, we can use this liquid either fresh or dried on blotting-paper as a means of identifying doubtful cultures of bacteria. The agglutinative reaction has now been shown to be of use, in both the ways just exemplified, as a means of identifying a considerable variety of diseases on the one hand, and-of bacterial species on the other. The diseases in which it has been found of value thus far are, first and foremost, typhoid in which its use has been firmly estab- lished since 1898. Probably the number of tests per- formed in this disease exceeds those performed in all of the diseases put together. Next to typhoid, Malta fever and epidemic dysentery of the type due to Shiga's bacil- lus are the diseases in which the agglutinative reaction between the patient's blood and the specific bacillus of the disease is most frequently performed. The reaction has also been found to be of value in the diagnosis of the bubonic plague, and it is apparently our only reliable means of diagnosis in cases of infection by the so-called paratyphoid bacillus, an organism closely allied to, but not identical with, the bacillus of Eberth. A certain amount of agglutination has also been de- monstrated in infections due to the tubercle bacillus, the pneumococcus, the pathogenic streptococci, and various others, but the reaction is not distinct enough to be clin- ically available. An agglutinative reaction may also be obtained with the serum of cases of glanders, whether in 131 Serum Diagnosis. Scrum Diagnosis. REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. animals or in human beings, but the usefulness of mal- lein has thus far prevented any widespread application of the agglutination test in glanders. Technique of Serum Diagnosis in Typhoid Fever. — First of all we must have a culture of the typhoid bacillus identified as such by all known tests. Bacilli that have recently been obtained from a human body are usually preferable. From such a well-identified stock culture, which is best grown on agar-agar, a loopf ul is transferred to a test tube containing about an inch of sterile bouil- lon. At the end of twelve hours at room temperature the bouillon will be slightly cloudy owing to the pres- ence of very actively motile bacilli. Such a culture re- mains lit for use for from twenty-four to thirty-six hours, at the end of which time a loopful of the bouillon culture should be transferred to another tube of sterile bouillon and so on, a new culture being started every twenty-four hours and all being kept at room tempera- ture, not in the thermostat. In order to be fit for use the bacteria must be very actively motile and show no ten- dency to spontaneous agglutination, such as often occurs in cultures more than thirty-six hours old. Since such spontaneous clumping occasionally occurs even in cul- tures frequently transplanted, it should be an invariable rule to examine, between slide and cover glass, a drop of the culture to be used, before adding any of the suspected blood. Spontaneous clumping is the most frequent source of error in performing the Widal test, for if we have added the blood of a suspected case without previ- ously examining the culture, and if agglutination is then found, we have no means of knowing whether it was produced by the action of the blood or had previously taken place in the culture. It should never be forgotten that the reaction is a quantitative one and not a qualitative one. If enough normal serum is added to a culture of typhoid bacilli and they be left in contact an hour or two, some agglutina- tion often occurs. The Widal reaction is the occurrence of agglutination in a particular dilution and within a specified time. The dilution recommended by Professor Welch of Johns Hopkins is one part of blood to fif t v parts of bouillon culture of typhoid bacilli. Any agglutina- tion which takes place in such a mixture, if accompanied by a cessation of motion within one hour, is considered a positive reaction. In my own work I prefer a dilution of 1 to 10 with a time limit of fifteen minutes. With a longer time limit this dilution often gives rise to mistakes, but among many thousands tests I have known not mors than one per cent, of mistakes, provided the short time limit (fifteen minutes) is rigidly enforced. Either the whole blood or the serum may be used, in fluid condition or dried on glass or glazed paper. The chief obstacle to using dried blood is the difficulty of se- curing accurate dilution. A full drop of blood should be allowed to fall upon a glass slide and dried. (In this condition it may be preserved for weeks without losing any of its properties, or may be sent by mail in case no laboratory is at hand.) To make the test the dried blood is simply scraped off into a test tube containing ten drops of a bouillon culture of typhoid bacilli. It is difficult to measure the size of the drops accurately, but in a vast majority of cases this degree of accuracy is unnecessary. The reaction is present in about ninety-eight per cent, of all cases of typhoid fever, but in a small proportion of these the reaction does not appear until so late a period of the disease that wo cannot use it for diagnosis.- In about two-thirds of all cases the reaction is present by the time the patient feels sick enough to consult a physi- cian, that is, somewhere about the end of the first week of the disease. After defervescence the reaction persists in many cases for three or four months, occasionally for years. In a case of this latter type, if the patient is' seen for the first time with some febrile affection and without knowledge of his previous history, the agglutinative re- action to typhoid still persisting in the blood may give rise to an error in diagnosis. As a matter of fact, how- ever, T have very rarely known this difficulty to arise. Technique of Serum Diagnosis on Other Diseases. — 132 Plague. Since the bacillus pestis clumps spontaneously in bouillon it has been found necessary (Kleiu, Lancet, June 8th, 1901) to make an emulsion of a small fragment of solid culture in 0. ?5-per-cent. solution. Cairns (Lancet, June 22d, 1901) has made three hundred tests in twenty- four cases by this method, and finds that in all but the mildest and the most rapidly fatal cases an agglutinative reaction appears hy the end of the first week in dilution of 1 to 10. This increases until by the eighth week a dilution of 1 to 75 is often insufficient to prevent agglu- tination. The time limit is fifteen minutes. In hanging- drop preparations agglutination within two hours often occurs in dilutions as high as 1 to 200. Malta Fever. The test is performed exactly as in typhoid. Agglutination is often found in dilutions of 1 to 100 or more with a one-hour time limit. Dysentery. The serum of cases studied by Vedderand Duval (Jour, of Exp. Med., February 5th, 191)2) agglu- tinated several strains of dysentery bacillus in dilution varying from 1 to 30 up to 1 to 500 within one hour. Controls with B. coli and B. typhosus were always neg- ative. The reaction does not always appear simultane- ously with the symptoms and may disappear in convales- cence with great rapidity. The clumps are usually like those in the Widal reaction. Rarely, long loose skeins of bacteria are formed. II. Serum Therapy. — As already intimated, serum therapy depends upon the fundamental fact thata group of body cells — for example, those of the central nervous system— have a way of rising to the emergency when compelled to defend themselves against a group of for- eign cells (e.g., tetanus bacilli) and of producing in ex- cess substances antagonistic to such foreign cells or to their products. Such an antagonism is known as immu- nity. To be immune against a given cell is to possess the power of poisoning or dissolving that cell. This is known as antibacterial immunity. When the body is attacked, not by cell groups but by cellular products, such as toxins, another type of immunity is produced by virtue of which the blood of the immunized individual is able to neutralize and render inert the toxin mole- cules. Either of these forms of immunity may be "natural" or "acquired," that is to say, the blood of many individ- uals contains substances similar in their action to anti- bacterial or antitoxic substances, even when the individ- ual has never, so far as we know, been obliged to repel the attack of foreign cells, or, in simpler language, has never had the disease against which he is thus immune. Thus negroes seem to be, for the most part, congenitally immune to malaria, in much the same way as maDy species of animals are immune to the typhoid bacillus. Acquired immunity is the result (a) of the disease, (b) of inoculation with the bacterial cells or the non-cellular toxins which cause the disease, or (c) of the inoculation of the body with the serum of persons convalescent from the disease in question or of some animal which has pre- viously been rendered immune to the disease. Immunity acquired as the result of infection, whether accidental or experimental, is known as "active immunity." That ac- quired as a result of the injection of serum from a con- valescent or immune animal is called "passive immunity." In the great majority of instances practical serum therapy consists in causing a patient to acquire a passive immunity by the means just described, but there are a few examples of serum therapy by which we endeavor to give the individual's blood antibacterial rather than antitoxic power. The diseases in which serum therapy has been used may be divided for convenience into those in which its utility has been definitely established, those still in the experimental stage, and tiiose in which experiment seems to have demonstrated that by our present methods im- munity cannot be conferred. In the first class we may group the following diseases in which it may be consid- ered that serum therapy has come to stay: 1. Diphtheria. 2. Tetanus. 3. Snake-bite. 4. Rabies. I will subdivide the next class into those diseases in REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. Serum Diagnosis, Scrum Diagnosis. which the outlook for serum therapy is very promising, and those in which it is distinctly less hopeful. Very promising have been the experiments with serum therapy in: (1) Bubonic plague; (2) acute epidemic dysentery; (3) typhoid. Less promising, but still hopeful, is the outlook in: (1) Cholera; (2) anthrax; (3) scarlet fever. Unpromising has been the result of our work so far in: (1) Tuberculosis; (2) pneumococcus infections; (3) strep- tococcus infections. A few experiments have also been made with sera in Graves' disease (milk of thyroidless goats), epilepsy (serum of epileptics between paroxysms), syphilis, and various other diseases with results thus far inconclusive. Diphtheria. Antidiphtheritic serum (into the details of its production I cannot here enter) is the serum of horses rendered immune to diphtheria toxin by increas- ing doses of the toxin administered subcutaneously. Its uses are two: (1) Prophylactic and (2) curative. Its prophylactic value in communities exposed to infec- tion (schools, hospitals, etc.) is very great. The immu- nity begins about twenty-four hours after the injection and lasts for from three to four weeks. For a young child two hundred and fifty units is a proper dose. For adults a proportionately larger dose is required. Its curative properties are now established beyond rea- sonable doubt. By its use the mortality in large con- tagious hospitals has been reduced from an average of forty-five per cent, to an average of sixteen per cent, (this last figure is based on an analysis of over 200,000 cases by Bayeaux). The mortality is less the earlier the serum is given in the course of the disease. In mild cases 4,000-6,000 units are sufficient. In severe cases 80, - 000-100,000 units mav be needed to save life. The single dose for adults is 4,000-8,000; for children 2,000-4,000, and the dose is to be repeated every four to six hours unless marked improvement shows itself after the first dose. Urticaria occasionally results from the use of antitoxin in diphtheria and may be very troublesome, but there ia no evidence that nephritis, neuritis, or any other severe complication is ever produced by the serum. Tetanus. Less brilliant than those of antidiphtheritic serum, the results of antitetanic serum are still such as place it far ahead of all other known remedies for tetanus. The great difficulty is to get it into the system sufficiently early in the disease. Two sera are used : (a) that of Behring and Roux ; (b) that of Tizzoni. The latter has been the more success- ful, but there is reason to believe that the type of dis- ease is milder in Italy. Pfeiffer * has recently collected the cases treated with Behring's serum and finds a mor- tality of 52.7 per cent. ; in 88 cases treated with Tizzoni serum the mortality was 36.3 per cent. The Behring serum is used in closes of 20 c.c. every five to ten hours. Of Tizzoni's product (solid) 2.25 gm. are used for the first dose and 0.6 gm. for subsequent doses. Recently cases have been treated by subarachnoid in- jections of the antitoxin by means of lumbar puncture, and there is some evidence that this method is preferable. Intracerebral injections have also been employed, but without any evident advantage. Preventive inoculations with tetanus antitoxin in cases of injury in a community in which tetanus has been prev- alent, have resulted in a marked lessening of the num- ber of tetanus cases developing. Snake Poisoning. Calmette's antivenene, 10-20 c.c, frequently repeated, is a most useful remedy especially for the bites of cobras and colubrine serpents, less so for bites of vipers or rattlesnakes. Antivenene appears in the serum of horses treated with increasing doses of cobra venom slightly modified by heat. Injected in patients suffering from a cobra bite it neutralizes one of the two poisons present in cobra venom —the nervous poison — and " enables the individual to de- * Pfeiffer: Zeit. 1. Heilkunde, xxiii., 3, 1902. vote all his vitality to overcoming the local injury " done by the other poison (the irritant) present in the venom. Since the nervous poison is the chief death-dealing agent in venoms antivenene is of great value and should be carried byall travellers likely to be ex posed to snake-bite. Rabies. Although the specific poison is as yet un known, much has been accomplished in the prevention of rabies by injections of what is probably a toxic serum (in all essentials) obtained from the spinal cord of mad dogs. Cords preserved in dry air gradually lose their virulence, and in the treatment of mad-dog bite in the human subject injections are begun as soon as possible after the bite, first with material from cords nearly de- void of virulence and later with material of gradually increasing virulence. The figures of the Pasteur Institute from 1886 to 1894 include 13,817 persons supposed to have been bitten by rabid animals. The mortality is 0.5 percent. Allowing for many mistakes in diagnosis we can hardly doubt that these inoculations have been effective, since the mortality, of the disease is usually estimated at from sixty to eighty per cent. Plague. Three sera are in use : 1. The Haffkine pro- phylactic vaccine. 2. The Yersin " antipest " serum. 3. The Lustig "antipest" serum. 1. According to Haffkine's own reports, the difference in mortality between those inoculated and those unin- oculated is from eighty to ninety per cent. As sample results he reports (Proc. Roy. Soc, vol. lxv., No. 418) an epidemic in the Umerkadi Jail: 127 uninoculated ; 10 cases, 6 deaths; 147 inoculated; 3 cases, no deaths. The vaccine has no effect on cases in which the disease is incubating at the time of inoculation. The dose is 2.5 c.c. The duration of immunity is not well determined. In a Russian village Tchistowitch (Annates de I'lnsU- tut Pasteur, March, 1900) succeeded in stamping out an alarming epidemic by the prophylactic use of Haffkine's vaccine. Its effects are very unpleasant, far more so than those of — 2. Yersin 's serum, which is used as a curative in cases of plague actually under way. Daily injections of 20-40 c.c. subcutaneously or intravenously have reduced the mortality from thirty -three to thirteen per cent, in Cal- mette's hands. The serum also conveys a brief prophy- lactic immunity (twenty-five to thirty days). Lignitire has used 40-60 c.c. at a dose (Annates de Vlnstitut Pasteur, October, 1901) with ninety per cent, of recoveries in cases in which the serum was employed early. Dysentery. Since Shiga's discovery of the bacillus of acute dysentery in the tropics, Flexner's identification of the same organism in the acute dysenteries of this coun- try, and the discovery of the same organism in the sum- mer diarrhoea of infancy by Vedder and Duval, work upon an antidysenteric serum has been pushed with eagerness. So far, the most definite results are those obtained in Japan and in Manila with Japanese serum from Kitasato's laboratory, but enough work has been done in this coun- try to make it evident that the outlook is not at all un- promising. Typhoid. The serum used in the vast majority of cases has been an antibacterial rather than an antitoxic serum, and has been administered as a prophylactic, not as a cure. Wright (Brit. Med. Jour., 1901, No. 2105) reports that among 2,669 uninoculated and 720 inoculated soldiers (Cyprus and Egypt, 1900) 68 of the former and onty 1 of the latter contracted typhoid. Birt (Brit. Med Jour., January 11th, 1902) noted at Harrismith (1900-01) the following data: Among 947 cases of typhoid in those not previously inoculated the mortality was 14.25 per cent. Among 203 cases of typhoid in men inoculated six to eighteen months before, the mortality was 6.8 per cent, and the type of disease milder. Sterilized cultures of typhoid bacilli are the material used for inoculation. Anthrax. Sclavo (Bert. Hin. Woch., 1901, pp. 480, 520) succeeded in obtaining from sheep, subjected to pro- gressive inoculation of anthrax bacilli, a serum efficient 133 Seven Springs. Sewerage. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. against the disease in sheep and apparently also in human beings. He refers to about twenty cases of human an- thrax treated with this serum in various parts of Italy, and states that most of the patients recover. Cholera. Working in the epidemic of 1894 at Cal- cutta, Haffkine inoculated with an emulsion of living cholera vibrios some 40,000 of the inhabitants. In one town, of 340 uninoculated, 45 got cholera and 39 died; of 181 inoculated, 4 'got cholera and 4 died. Among 18 people living in one house, 11 were inoculated and no cholera occurred in any of them. Seven were not inocu- lated, 4 of them took the cholera, and 3 died. The inoc- ulations cause a rise of 1° to 2° C, lasting with some con- stitutional symptoms for twenty-four hours. Scarlet Fever. That the serum of patients convales- cent from scarlet fever seems to exercise a favorable in- fluence on the course of active cases has been noted by many observers (e.g., Huber and Blumenthal, Berl. klin. Woeh., 1897, No. 31, and Leyden, Munch, med. Woch., January 18th, 1902). More recently sera prepared from streptococci isolated from the organs of scarlet fever cases have been used especially by Baginsky (using Aronson's serum) and by Moser, using a serum of his own manufacture. Each re- ports good results. Richard O. Cabot. SEVEN SPRINGS. — Washington County, Virginia. These springs are located two miles from the Glade Springs. Dep6t, on the Norfolk and Western Railroad. They have been known for many years, but no accom- modations have as yet been provided for visitors. The waters are used commercially in the form of Seven Springs Iron and Alum Mass, an evaporated residue. An analysis of this mass by Prof. J. W. Mallet, of the Uni- versity of Virginia, showed the presence of a large pro- portion of aluminum sulphate and iron persulphate, be- sides a considerable quantity of magnesium and calcium sulphate, and numerous other ingredients in smaller pro- portion. This substance is highly recommended as a general tonic and reconstructive, and is said to possess special merits in such affections as cholera morbus and dysentery, and in various hepatic and intestinal disorders. James K. Crook. SEWERAGE AND SEWAGE DISPOSAL— A system of sewerage is the network of pipes, conduits, etc., con- structed for the purpose of collecting and carrying away from a city, town or village, the wastes of human life other than that portion of the wastes which are known collectively under the term garbage. The wastes enter- ing the sewers may come from houses, stores, stables, factories, etc., and, if the sewerage system is constructed upon the so-called combined jjlan, the sewers will also carry street wash. If the system is constructed upon the so-called separate plan, street wash will be excluded, to be cared for by means of drains built for that purpose. The volume of sewage flowing in the sewers of a town or city of a given population depends mainly upon three things: (1) The consumption of water; (2) the tightness of the sewers, that is, their ability to prevent the entrance of ground water ; and (3) whether the sewers are on the so- called separate or on the combined system. In England and upon the Continent, where the consumption of water does not average much more than thirty gallons per capita per day, the average volume of sewage produced by a given population must necessarily be less than in America, where the consumption of water in our largest cities and towns varies from seventy -five to two hundred and fifty gallons per capita per day. Upon the tightness of the joints of the pipes of the sewer system rests a great deal of responsibility in regard to the volume of liquid entering these sewers. By careful construction of the sewers and in some soils the ground water may be almost entirely excluded, but faulty construction in porous soils will often allow the entrance of a volume of ground water sometimes fully as great or greater than the vol- ume of true sewage. In the combined system of sewage the volume of sewage flowing in the sewers is very much augmented at times of storm by the addition of street wash. After collection in sewers some satisfactory method for the disposal of sewage is necessary. Formerly it was considered sufficient to empty this sewage into some body of water or flowing stream, which would either dilute it sufficiently to prevent visible nuisance, or carry it away from the vicinity of the town or city producing it. This method can still be carried out without offence by fortunately located cities and in sparsely settled coun- tries with large rivers, lakes, and streams. As a country becomes more thickly settled, however, it is not sufficient simply to pass the sewage from its source to a point where it will not cause a nuisance to those producing it, but it must also be cared for in such a way as to prevent it from becoming a nuisance or a source of danger to other communities. On this account and coincidently with the great increase of urban life in civilized countries during the past twenty-five years, the question of sewage disposal has become a most pressing one. So general had the nuisance caused by sewage entering streams become in England as early as 1876, that the Rivers Pollution Prevention Act was passed — a law providing that no rivers or streams should be. polluted because of the ad- mission of crude sewage. In the twenty-seven years elapsing since that time there has been a constant agita- tion in England upon the subject, with an idea to better- ing the condition of the rivers and streams, but even now the Act is very imperfectly carried out. Practically the first agitation of this question in Amer- ica was in the State of Massachusetts. The report of the State Board of Health for 1876 contained an article by the then secretary of the board, in regard to sewage dis- posal systems in England and on the Continent, and the same volume contained a report by an engineer of an examination in regard to the condition, on account of sewage pollution, of certain rivers and streams of Massa- chusetts. Since that date more important investigations upon sewage disposal and purification have been accom- plished than during any previous period. An outline of this work, however, with descriptions of the most impor- tant methods, is all that can be given here. It is also well to state at this place that in this article little mention can be made of methods of dry disposal of wastes. These methods do not properly come under the head of sewage disposal, but they are methods in vogue in towns, dwell- ings, public buildings, etc., by means of which the wastes are collected in such manner as to render them more or less valuable for fertilizing purposes ; that is, either with- out having been diluted or mixed with water, or only to a very slight extent. Besides the common middens, privies, etc., many patent processes for the accomplish- ment of the same result are in vogue in different places, and many processes by which by some means the solid matter of these wastes is, even when mixed with water, separated more or less efficiently from it before the main body of liquid enters the sewers The demands made upon modern engineering in com- plex and difficult sewerage construction are very great, and as a result methods of construction are constantly improving. Sewerage works are increasing enormous- ly, in number, in the area covered by a single system, and in the volume of sewage collected at a single point. The volume of sewage thus collected for disposal by a single city or metropolitan district now often reaches into the hundreds of millions of gallons daily. Direct Disposal into Bodies of Water, or Disposal ly Dilution. — Fortunately located cities and towns can sat- isfactorily discharge their sewage unpurified into large bodies of water. Where such communities are in close proximity to the seacoast or upon a very large river, the discharge of unpurified sewage into tidal waters or swift currents is still resorted to successfully. The method is practically without expense after the sewerage system is once complete, other than that, in some instances, of pumping. It is efficient if the tidal or other currents are strong and the sewage is prevented in this manner from reaching adjoining shores, and if the volume of water 134 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Seven Springs. Sewerage. into which the sewage is discharged is large compared with the volume of entering sewage. In some instances, however, even in such locations, some attempt at partial purification is made by collecting the sewage in basins and allowing sedimentation to occur before the discharge of the supernatant liquid ; this sedimentation often being aided by the use of chemical precipitants. Beginning in 1852 the straggling sewers of the city of London were given more definite form, and the sewage of this city was collected and carried by means of sewers to Barking Creek and Crossness, twelve miles below Lon- don Bridge. This enormous work was made necessary by the polluted condition of the Thames River. Before this date the sewage was discharged through many sewers directly into the Thames, as the river passed through the city. The greater part of the new works emptying at Barking Creek were completed in 1864, and in 1865 works on the opposite side of the river at Crossness were also completed. Ten years after the opening of these works it became necessary, on account of sewage carried up the river from these outfalls, to build large settling tanks in which the sewage was collected and chemicals were added for the purpose of precipitating the solid matter before discharging the clarified sewage into the tidal estuary. The solid matter resulting from this precipitation is taken out to sea in sludge boats, and the sewage is discharged be- tween high and the middle of ebb tide. During 1901 and 1902 the average volume of sewage discharged daily amounted to 234,508,000 gallons and 47,673 tons of sludge were carried to sea each week. Twenty-two thousand tons of protosulphate of iron and five thousand tons of lime were used during the year. Boston, Mass., together with the cities and towns sur- rounding it and composing a metropolitan district, with a population of 1, 200, 000 and having an area of 187 square miles, collects its sewage into three main systems, all of which discharge into strong tidal currents in the outer parts of Boston harbor. With two of these systems the discharge is continuous, while in the other the sewage is collected in large storage tanks and allowed to pass out on the ebb tide. Two of these points of discharge have been in [operation for many years, and, notwithstanding the volume of the sewage, amounting at the present time to about 120,000,000 gallons daily, so efficient is the dis- posal because of dilution, sedimentation, and the rapid carrying away by swift tidal currents, that well-patron- ized summer resorts exist within short distances of the points of discharge. The sewage of Greater New York all empties into New York harbor by means of many sewers, and is so diluted and dissipated by the swift and deep tidal currents that it is well cared for and practically unnoticeable. The sewage of Buffalo enters the Niagara River between Lakes Erie and Ontario. The sewage of St. Louis enters the Mississippi River, as does now the main portion of the sewage of Chicago through the Chicago drainage canal and the Illinois River, and in each instance, on account of the large volume of water flowing in the river, the disposal from some points of view is adequate. Sewage Farms. — Berlin, Germany, passes its sewage to immense sewage farms, which have been in operation for many years, and are eleven thousand acres in extent; Paris, a portion of its sewage to farms at Gennevilliers and other places, where it is adequately cared for. Many other cities and towns, both in Great Britain and upon the Continent, follow the same method of disposal satisfactori- ly. This method can be carried out successfully, however, and at a profit to the farm only where the sewage is com- paratively rich in organic matter, that is, where the volume of water is small compared with the population produc- ing the sewage. It is with considerable difficulty even then that these farms can be made to return a profit above the cost of operation. It goes without saying that American sewage cannot be disposed of satisfactorily in this manner, being altogether too dilute ; and any attempt so to utilize it means generally the use of only that portion valuable for irrigation, with the direct discharge of the remainder, unpurified by filtration through the soil, into the most convenient body of water. Sewage irrigation or farming, however, was the first attempt properly to purify sewage upon land, but having, sometimes at least, for its main object the utilization of the sewage rather than its purification ; a profit from the farm being deemed of more importance than purification. Continual agitation upon the subject of the prevention of the pollution of streams by sewage making a wide- felt demand for a thorough understanding of proper and efficient purification, scientific studies upon this subject were begun practically about eighteen years ago. It had been observed that the passage of sewage through soil not only caused the removal of the suspended matters, but that the matters in solution were also changed or de- stroyed, that is, they did not appear in the effluent unless in an unrecognized form. The knowledge df germ life and the science of bacteriology having practically its beginning at about this period, it was believed that these changes occurring in sewage were caused by bacterial life in the soil. These first investigations were made by Schloessing and Muntz in France, and Warrington and Frankland in England. Their experiments were upon a laboratory scale and, without attempting to show that bacterial life was present by means of observation, they did demonstrate that, if germicides were added to the filter or to the sewage, purification in the filter did not occur. They also observed that their small tube filters, containing the earth, marbles, and other media experi- mented with, not only purified the sewage, but the filters themselves remained fairly clean, and organic matter accumulated very slowly within them. These investi- gations were very meagre and not long continued. Toward the end of 1887, however, the State Board of Health of Massachusetts established an experiment sta- tion for investigations upon the subject of sewage puri- fication, and accomplished and published the results of the most important scientific studies that had ever been made upon this subject. This experiment station is still continued. During the past eight or ten years much work along the same lines, but upon a larger scale, has been done in England, practically all of this work being based upon the Lawrence data, with such additions in construction of filters and methods of application of sew- age as local needs have suggested. Many of these Eng- lish studies have been largely carried on by cities and towns with the intention of applying the results directly to their own problem of sewage disposal, and thus have a practical and in some cases limited bearing only, and are without such thorough investigation of the science of the subject as has been aimed at in the long-continued Mas- sachusetts experiments. Sewage farming having caused the recognition of the fact that it could not be successful except with compara- tively small volumes of strong sewage and where land was plentiful and cheap, nearly all the scientific investi- gations at the Lawrence experiment station have centred upon evolving processes of sewage purification by means of which the largest possible volume of sewage can be efficiently purified upon the smallest possible area and at a minimum cost. These studies have nearly all been upon bacterial methods of purification, that is, the oxi- dation or purification of the organic matter in sewage by means of the bacteria which establish themselves sooner or later in sewage filters of all kinds. With these stud- ies others have been made in regard to methods for the treatment of sewage preliminary to filtration, which would result in allowing larger volumes to be efficiently purified upon given areas than is possible with untreated sewage. Theory of the Bacterial Purification of Sewage. — In the purification of sewage by the action' of bacteria the proc- ess is about as follows: The bacteria in the sewage, in the presence of oxygen, first attack the carbonaceous matters, carbonic acid being formed, nitrogen and hydro- gen are set free and unite to form ammonia, this in turn uniting with the carbonic acid, forming ammonium car- bonate, which goes into solution. The next step is the oxidation of the nitrogen of the free ammonia, first to 135 Sewerage -and Sew- ago Disposal. REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. nitrous acid and then to nitric acid, by the nitrifying bacteria working in the presence of oxygen. The citric acid then unites with a base, such as sodium or potas- sium, present in the sewage or the filter, and sodium or potassium nitrates are formed. These are, in the small amount present, innocuous mineral salts, and appear in solution in the effluent. In this work of the bacteria much of the organic matter is also changed to gase- ous forms, and many gases are set free. If filtration through properly prepared filter beds is carried on slowly enough, all the organic matter in the sewage applied to these beds can be changed either to gaseous forms, such as carbonic acid, ammonia, free nitrogen and hydrogen, which escape into the air, or to mineralized bodies, which appear in solution in the effluents of the filters. Such thorough purification as this, however, is not generally necessary, nor is it practicable in many instances, except where the volumes of sewage to be dealt with are com- paratively small and where land is cheap. Intermittent Filtration. — Next to sewage irrigation or farming, in which mere driblets of sewage are generally applied to each acre under cultivation — at Berlin the volume is from five hundred to five thousand gallons — the best results and the best purification can be obtained by filtration through properly prepared filter beds of sand or similar material. In order that good work may be done in such beds they must be constructed of sand coarse enough to allow sewage to enter easily, and the sewage must be applied in such a manner, at such intervals and in such volumes, that it will pass through the entire area of the filter in a fairly uniform manner, and meet an abundance of oxygen within the filter. Physical Characteristics of Sand Used for Filtration. — At the Lawrence experiment station a method for de- termining the efficiency of sands in sewage filtration was elaborated from practical experience. By this method the sand is sifted through sieves, these sieves being so calibrated that the approximate size of the sand grains passing through can be easily determined. It was found that the quantitative and qualitative efficiency of sands used in filtration depends to a considerable extent upon the finer particles present. Owing to this, a certain arbi- trary standard was adopted, called the " effective size " ; this being the diameter in millimetres of the finest ten per cent, by weight of the sand grains. Following this standard, if a sand is stated to have an effective size of 0.25 mm., the meaning is that ten per cent, by weight of the sand consists of grains with an average diameter less than this figure. The determination of the volume of water which a certain depth of sand of a known grade, well underdrained, will hold by capillarity is easily made. The knowledge of these two facts gives adequate data to enable one to foretell the volume of sewage which can be held by a well-underdrained sand filter of a given depth, or, in other words, its time of passage through such a filter when successive applications are made ; this hav- ing a direct bearing upon the volume that can be purified satisfactorily and successfully upon a given area. An average sand has about thirty -five per cent, of open space ; that is, when this sand is dried and packed as closely as natural, the space between the grains filled with air amounts to about thirty-five per cent, of the total volume of the sand. This percentage of open space differs but little with coarse and fine sand. When a coarse sand, well underdrained, has water applied to it for a considerable period, it will hold but a small portion ; of this water by capillarity, while each finer grade will • hold more and more, until a grade is reached that will hord itself practically saturated to within a few inches of its surface ; that is, the open or air space present when the sand is dry will be filled with water. Mate of Filtration Through Sand Fillers. — A sand as fine as this last grade, which will in fact resemble clay is practically useless in sand filtration of sewage. Any sand, ten per cent, by weight of the grains of which have a smaller diameter than 0.05 mm., is of small value for sand filtration, especially in a cold climate where freezing occurs in winter, although areas constructed 136 of a grade of sand as fine as this can be used if trenched with coarse sand, and if the sewage is applied to these trenches. All grades of coarse sand are valuable for filtration purposes, none being too coarse to effect good results, if the underdrains of the area are placed at sufficient depths and a proper distance apart. A rate of filtration equal to 100,000 gallons per acre per day can easily be maintained upon coarse sand filters with sewage of average strength. On two filters of the same grade of coarse sand the rate that can be maintained depends very largely upon the strength of the sewage ; that is, upon the amount of orgauic matter present in each unit volume of water going to make up the volume of sewage. Many weak sewages from towns having a considerable lengfhof pipes laid but with comparatively few connections, or systems into which ground water enters in considerable volume, can be filtered through sand with satisfactory purification results at rates at least three times as high as the figure given above — that is, if the filters are prop- erly cared for. Care of Sand Filters. — The care of sand filters is, of course, one of the main points in maintaining permanency of operation. In order that the surface of the beds may not become clogged, much of the matter reaching them iu suspension in the sewage either has to be raked up and removed from time to time, or else ploughed under. With a fresh sewage — that is, a sewage where the mixt- ure of filth and organic matter of all kinds with the wastewater of the town has just occurred and little time has been given for mechanical, chemical, and bacterial actions to take place in the sewers — we have a liquid containing organic matter in quite a different form from the same matter in the sewage when opportunity has been given for these various actions to take place. A fresh sewage generally contains free oxygen, nitrogen in the form of nil rates and nitrites, the proportion of or- ganic matters in suspension to those in solution is com- paratively large, and the matters in suspension are in comparatively coarse particles. When sewage reaches a filter area in this condition, the matters in suspension are easily strained or filtered out upon the surface of the bed and can be removed by raking. If then they are mixed with loam or sand— that is, composted— they cause little or no offense, and even when placed in a heap without mixture with soil or loam, the organic matter generally decomposes so slowly that little, if any, nuisance occurs. As fresh sewage flows along in the sewers and me- chanical, chemical, and bacterial forces have a chance to act upon it, the organic matter present undergoes a decided change. The chemical and bacterial chance is practically the breaking up of the organic matter "into simpler forms, and the mechanical change is the disinte- gration of the matters in suspension into finer particles. Sewage in this condition— that is, with much of its sus- pended organic matter either changed to soluble forms or finely disintegrated— is designated as stale sewage, and, when it flows upon a filter bed, much more of the or- ganic matter present in it is carried into the pores of the filter than when the sewage reaches the bed in a fresh state. Upon the surface of beds receiving such sewage, little mat- ter accumulates that can be removed by raking, but the disappearance of this matter by bacterial oxidation can be very much aided if the surface of the bed is loosened from time to time by raking, harrowing, or ploughing. Method of Operation of Sand Filters.— In order to purify sewage satisfactorily while passing it through sand fil- ters, an abundance of air in the pores of the filter is a necessity. To assure the presence of this air, the appli- cation of sewage must be intermittent— that is, it must be applied from time to time and in limited volumes. If we should apply sewage continuously to a sand filter, keeping the surface of the sand covered with sewage, the entire open space in the filter would become filled wilh liquid, air would be excluded, and those organisms which oxidize the organic matter by working in the pres- ence of air would be either destroyed or rendered unable to work successfully. This fact has often been proved, and is what occurs when attempts are made to purify REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Sewerage and Sew- age Disposal. sewage by passing it in any but very limited amounts through soil or clay — materials useless in sewage purifi- cation. Instead of oxidation in such beds, if they are overworked, we have reducing actions occurring, oxygen is taken from the oxides in the soil or clay or sand, and the base of these oxides passes into solution. Putrefac- tion of the organic matter of the sewage also occurs, with the production of odors, and an effluent often less pure than the applied sewage is the result. In order to pre- vent this the volume of sewage applied to any intermit- tent sand filter must be such that under no conditions will the sewage entering the filter exhaust the air pres- ent, or keep the surface of the filter covered for too long a period. The volume of sewage which can be applied to filtersof coarse or fairly fine sand with good results varies comparatively little, but the method of application should vary considerably if good results are to be obtained. That is to say, with a filter of fine sand the sewage should be applied in large doses as it enters the filter slowly, and when once it has passed below the surface of the sand a considerable period should elapse before another appli- cation is made, in order that air may enter the upper por- tion of the filter. With a filter of coarse sand, into which the sewage enters readily, more frequent applications of a smaller volume of sewage is the preferable manner of operation, in order that the sewage may not pass through the filter too quickly. Much air may be made to enter the filter by this manner of flooding, as the sewage dis- appears quickly from the surface of the coarse sand. This difference of action of different sands can be modi- fied very much, however, by different distribution of the underdrains. By such equalization as can be obtained in this way a filter of coarse sand may be worked practically in the same manner as a filter of finer sand, and vice versa. The following table shows first the average results for one year obtained when filtering sewage through two different experimental filters that had been in operation for ten years at the Lawrence experiment station when these results were obtained. One of these filters (A) is constructed of coarse mortar sand and the other (B) of fine river silt trenched with a coarser sand, the coarse filter being operated at a rate three times as great as the fine filter, or approximately 60,000 and 20,000 gallons per acre daily respectively. In the same table are given the results from a third filter (C) of coarse sand, operated at a rate of 300,000 gallons per acre daily, the sewage ap- plied to this filter being of such strength, however, that 300,000 gallons contained no more organic matter than the 60,000 gallons applied to Filter A: Table I.— Parts per 100,000. Sewage (A and B). Filter A. Filter B. Filter (J. Ammonia- 3.8200 .8000 .3803 .4200 8.4800 .0000 .0000 3.9001 1 4,700,000 05502 .0697 8.3600 2.7100 .0118 .45(10 28,800 0.C660 .0100 7.891,6 2.9300 .0003 .1100 £8 0.0404 Albuminoid — Total .0308 2.8200 Nitrogen as— Nltr rtes 1.2500 .0044 .3400 Bacteria percubic centimetre . . 15.800 In calculating the percentage of purification obtained by filtration the common method is to show the removal Percentage Purification-. Albuminoid ammonia. Bacteria per cubic centimetre. Filter A 91.3 97.9 £6.2 C9.4 Filter B C9.9 Filter C 99.7 or oxidation of organic matter as shown by the determin- ations of albuminoid ammonia in the sewage applied to and the effluents from the filters, and this is given in this instance in the table below. True purification in sand filtration is by nitrification, and it will be noticed that the nitrogen appearing as nitrates in the effluents of Fil- ters A and B in the accompanying table, accounts for a large part of that present in the sewage as free and albu- minoid ammonia. Sand Filter Areas. — Massachusetts has more sand filter areas for the purification of the sewage of cities and towns than any other State in the country at the present time. These filters are in successful operation, and undoubt- edly produce better results in the New England climate than could be obtained the year round by any other method of filtration yet known. At the end of the year 1902 there were fifteen cities and towns in the State, be- sides many large institutions, disposing of and purify- ing their sewage upon sand areas. It is well to describe one or two of these areas, with the results which are being obtained from them. SeiDage Disposal System of Broekton. — The city of Brockton has a population of approximately 40,000. The sewerage system was first put into operation in the year 1894, the sewage being conveyed through main sew- ers to a pumping station on the outskirts of the city. At this pumping station the sewage is received into a cov- ered masonry reservoir, from which it is pumped to the filtration area. In designing this system it was planned to take house sewage only, and to exclude all surface water and as far as practicable all ground water from the sewers. There are several main lines of brick sowers, but the principal part, of the system is constructed of pipe sewers. The main sewer, which is brick, is laid in the valley of a river and considerably below the level of the water in that river. On this account at times of high water in the river the surface of the ground in the vicin- ity of the sewer is flooded. "When the main sewer was completed and before any connections had been made, the amount of leakage into this sewer was measured at a time when the water in the stream was low, and the results were as follows: In a section of the sewer about 2,000 feet long the leakage of ground water was found to bo about 17,000 gallons per day, or about 45,000 gal- lons per day per mile of sewer. The entire amount of leakage in the main sewer amounted to about 61,000 gal- lons per day per mile of sewer, and this has increased, when the meadows along the river are flooded, to about 178,000 gallons per day per mile of sewer; these figures being given to illustrate the amount of ground water which may in some locations enter a well-constructed sewer. The measurements were made in a section of brick sewer of a maximum size, at the lower end, of 23 by 48 inches, underdrains were built beneath the sewers to take care of the ground water, if possible, and particular care was taken in construction to make the sewer tight. From the masonry reservoir already mentioned, which has a capacity of 619,000 gallons, the sewage passes through screens consisting of iron slats with an open space between them of three-quarters of an inch, and then to the pumps. It is necessary to clean the screens several times each day while the pumps are being oper- ated, and the material removed is burned beneath the boilers in the pumping station. The solid matter which accumulates in the reservoir is stirred up from time to time and pumped to the filter beds, this stirring being done by means of an agitator, consisting of perforated pipes laid on the bottom of the reservoir and connected with the force main through which sewage can be dis- charged under a head. The force main from the pump- ing station to the filtration area is a cast-iron pipe 24 inches in diameter and 17,500 feet in length. The filtra- tion area comprises approximately thirty-nine acres, on which twenty-three filter beds have been constructed, each having an area of about an acre. The beds were prepared for receiving sewage by the removal of the loam from the surface, and from twelve beds the subsoil was also removed. The sewage is distributed on the beds by means of wooden carriers which are laid across the bed from the centre of one side, so arranged as to 137 Sewerage and Sew- age Disposal. REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. discharge the sewage at several points. The grade of sand and soil in these beds differs very widely in different beds and in different portions of the same bed. The subsoil has an effective size of about 0.07 mm., and the effective size of the various grades of sand found varies from 0.07 to 0.75 mm. The underdrains in the filters are laid about sixty feet apart and discharge into two main underdrains. The heavy sewage which accumulates in the bottom of the reservoir is, when pumped to the beds, generally discharged upon a special sludge bed. The average volume of sewage reaching these beds amounts- to about 900,000 gallons per day. The average analysis of the sewage and effluent during a certain period is shown in the following table: Table II.— Parts per 100,000. Sewage. Effluent. Residue on evaporation- 72.0200 34.9200 4.7383 0.9058 .4983 .4075 10.9100 13.0366 48.3000 Ammonia— .1633 Albuminoid- .0163 10.4200 Nitrogen as— 3.1667 Nitrites .0056 .1700 The percentage purification obtained by these beds is about ninety -eight per cent., as shown by the organic matter determined as albuminoid ammonia. Sewerage and Sewage Filtration at Marlborough, Mass. —Marlborough is a Massachusetts city of about 17,000 people. The sewerage system was constructed in 1891, and was designed to take house sewage only. All the sewage is collected in a system of pipe sewers and con- veyed by gravity through a main pipe sewer to settling tanks and filter beds about three and one-half miles away from the city. In constructing the sewers considerable ground water was encountered, and a large amount of this water leaks into these sewers. In this city, in dis- tinction from Brockton, no underdrains were laid beneath the sewers to care for the ground water. The average amount of sewage reaching the beds dailyis about 1,500,- 000 gallons, the amount varying very much at different times of the year. Accurate measurements have shown that the volume during wet months, such as in the early spring, is four or five times that flowing in the dry months of the late summer and early fall. The sewage at the filtration area enters settling tanks, two in number and with a combined capacity of 16,000 gallons. When the average volume of sewage is reaching these tanks, it is about twenty minutes in passing through them, this time being very much decreased as the volume of sewage increases, and of course increased when the volume of sewage decreases. The material which accumulates in these tanks is usually removed about once each fortnight and is discharged upon special sludge beds, where it is allowed to dry, and is then raked up and carried away, this material being used by the farmers in the vicinity as a fertilizer. The sewage in the tanks passes upward through horizontal screens having a one-inch mesh, be- fore its discharge into the carriers leading to the filter beds. There are twenty-six of these beds having a com- bined area of about eleven acres. In preparing them nearly all the loam was removed, but the subsoil was al- lowed to remain in place. The beds were originally un- derdrained by lines of pipe about fifty feet apart, with a depth of from five to eight feet beneath the surface. On account of these drains receiving a large amount of ground water, it was found that their capacity was in- sufficient to remove both ground water and effluent, and additional underdrains were put into place. The material in the beds is quite uniform in grade, and has an effective size of about 0.14 mm. The sewage is discharged upon these beds near the corners, and the FIG. 4189— A Massachusetts Filtration Area. 138 REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. Sewerage and sew age Disposal. Fig. 4190.— A Massachusetts Filtration Area. general method has been to turn all the sewage on to one, two, or three beds, according to the quantity flow- ing, and allowing it to flow upon these beds for twenty- four hours. In wet weather, of course, the flow has to lie more widely distributed over the entire area. The sewage is applied to the beds in rotation, and once in ■about five weeks the surface of each of the beds is raked to remove the surface deposit, and then harrowed and .allowed to remain out of operation for a short time ; the solid matter which accumulates on the surface being re- moved before the surface is harrowed. In the fall the beds are ploughed and the surface is left in ridges and fur- rows, so that the ice forming upon the beds rests on the ridges and protects the sand from freezing, the sewage running in the furrows beneath this ice. The beds re- ceive no attention in the winter in regard to surface management, but in the spring they are raked and then ploughed, harrowed, and graded, and remain level throughout the summer. The average rate of nitration at this area approximates 100,000 gallons per acre daily. The following table gives a fairly average analysis of the sewage applied to and the effluent from this area: Table III.— Parts pee 100,000. Sewage. Effluent. Residue on evaporation — Total 61.0000 37.0000 2.4000 .5800 .2000 .3800 5.8000 3.9000 24.8000 jnmonia— .6203 Albuminoid- .0328 5.0000 Nitrogen as— .5400 .0171 .3400 The average purification by these beds is about ninety- iour per cent. ; that is, ninety-four per cent, of the organic matter in the applied sewage does not appear in the effluent from the filters. Chemical Precipitation. — In the early days of sewage disposal, when it was considered that in most instances the removal of the larger portion of the matters in sus- pension in sewage was efficient purification, the coagula- tion of these matters by means of chemical precipitants was a favorite process, and very many costly works were erected in England and on the Continent, to be used in purifying or clarifying sewage in this way. The chemi- cals most generally used in chemical precipitation are lime, sulphate of alumina, and salts of iron. These chem- icals by decomposition form, with other elements present in the liquid, gelatinous bodies like aluminum hydrate, which entangle or coagulate a considerable percentage of the organic matters in suspension in the sewage, together with some of the matters in solution. The specific grav- ity of the precipitant and coagulated sludge causes more or less satisfactory sedimentation to occur. The super- natant liquid is then run off, and the accumulated sludge either passed to sludge beds or to filter presses, or both. The filter press is simply a machine in which the sludge is placed to undergo compression whereby it is freed from a considerable percentage of its water, while the solid matters are retained by the cloth bagging in which the sludge is placed. Sometimes this sludge, when suf- ficiently dry, will be carted away by farmers, to be used as a fertilizer, but generally only after having had a very large percentage of its water removed from it by press- ing ; and more frequently it cannot be disposed of in any way except by the expense (chargeable to the operation of the works) of carting it away to be composted, or used in filling in low ground. This method of sewage treatment is in use in many places in England and on the Continent, and in a few places in this country. Its successful use, however, is generally confined at the present day to such locations as London, England, or Providence, R. I., where all that is at present considered necessary in the treatment of the sewage is the removal of the suspended matters; 139 Sewerage and Sew- age Disposal. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. this being so at these places on account of their proximity to large bodies of salt water and the opportunity thus of- fered for the removal and dissipation of the sewage by dilution and tidal currents. At Worcester, Mass., is a good representation in this country of a well-managed chemical precipitation plant. Worcester is a city of about 110,000 people, the natural drainage of which is into a river which flows through the city. The plant for chemical treatment of the city's sewage was constructed largely in 1891, although addi- tions have been made to it since, as the growth of the city and the increase in the volume of sewage to be dis- posed of have required. At these works there are sixteen precipitation tanks, about 100 feet long, 66.7 feet wide, and 7 feet deep. When the works were first put into use, the volume of sewage treated was about 3. 88 million gallons per day, and in 1901 it was 9.76 million gallons per day. The sewage on its way to the tanks passes through screens, and is there mixed with chemicals. From these screens it passes through a mixing channel to the first precipitation tank and then continuously through the series of tanks, at the end of which it is dis- charged over a weir. Lime and sulphate of alumina are generally used for precipitation. The sewage, however, is of a rather unusual character owing to the discharge into the sewers of much waste from iron and wire works, in which large quantities of acid are used. On account of this the sewage is sometimes acid and contains sulphate of iron. When in this condition no sulphate of alumina is used, lime alone being added in sufficient quantities to decompose the sulphate of iron and allow precipitation. In the addition of the chemicals they are powdered and then passed through hoppers into agitators, where they are well mixed with a small amount of sewage. From these agitators this sewage containing the chemicals is discharged into the main body at the head of the mixing channel. About one ton of chemicals per million gallons of sewage treated is used. During 1901 the purification effected by this plant was shown by the following table: Table IV.— Parts per 100,000. Ammonia— Free Albuminoid — Total In solution In suspension . Chlorine Oxygen consumed . Sewage. 1.7500 .6210 .2390 .3820 9.180.1 8.6700 Effluent. 1.6260 .3180 .2620 .0560 8.9500 4.1000 This table shows that approximately forty-nine per cent, of the organic matter determined as albuminoid ammonia was removed, and about fifty -three per cent, of the organic matter determined by the oxygen-consumed method. By operating the plant in the manner followed at Worcester the volume of wet sludge produced amounts to about 1.5 per cent, of the total volume of sewage treated. A series of experiments upon the removal of organic matter from sewage by means of chemical precipitation was made at the Lawrence experiment station, continu- ing from 1890 until 1898, and the results showed that generally about fifty per cent, of the total organic matter could be removed from the Lawrence sewage by this treatment, and a considerably greater percentage of the matters in suspension only. As good results were ob- tained with the normal alkaline sewage of Lawrence when using one thousand pounds of chemicals per one million gallons as when using a greater amount, and, of the various precipitants tried, sulphate of alumina gave on Ihe whole the best results. The chemicals used in precipitation are of low cost per pound, but when a large volume of sewage is to be treated, this expense amounts to a serious sum. At Worcester during 1901 the cost of operating the precipitation plant was §43, 774 or $12.27 per one million gallons of sewage treated, a very large portion of this expense being for the chemicals used and for treatment of sludge. By chemical precipitation the amount of organic mat- ter present in sewage can be reduced very greatly before the main body of sewage is allowed to run to waste, as the figures already quoted show. The organic matter in solution, however, is affected but slightly by this treat- ment, and this is really the matter which is in the proper condition to putrefy first — that is, it is the most offensive matter in the sewage as the sewage undergoes decay. On this account clarification by chemical precipitation is but a partial purification at best, and in order really to purify the sewage, a further treatment of the effluent of the precipitation tanks must be resorted to. That is, this is necessary if a stable or non-putrefying effluent is to be obtained. Up to the present time this has usually been accomplished by filtration through sand. Almost with the inception of the work upon chemical precipita- tion at the Lawrence experiment station sand filters were put into operation to receive the sewage clarified in this way. For example, the supernatant liquid from treat- ing Lawrence sewage with sulphate of alumina, at the rate of one thousand pounds per one million gallons and allowing four hours for sedimentation after the addition of the chemical, was applied for over four years to a sand filter containing five feet in depth of sand of an effective size of 0.17mm., and at an average rate of 200,000 gallons per acre daily. This rate was from two to three times as great as could have been followed successfully upon the area used if untreated Lawrence sewage had been ap- plied. A well purified, well nitrified, "clear, and stable effluent was always obtained, and at the end of the ex- periment the filter used was in good condition. The upper few inches of sand were somewhat clogged with organic matter at the end of this period, but no more so than was to be expected when filtering sewage at this rate. At Worcester it has been recognized that the effluent from the filtration plant would not have the desired effect in rendering the river into which the sewage for- merly flowed very much less objectionable unless fur- ther treatment was given the sewage, especially as the volume of sewage is increasing steadily as the popula- tion of the city increases. On account of this, sand fil- ters are being constructed there, upon which a portion of the sewage runs after chemical treatment. At the end of 1901 the city had 14.5 acres of filter beds. These fil- ters received during the year 220,000 gallons per acre daily of partially purified sewage, and when the chemical effluent alone was being passed to them, they were at times operated at the rate of 300,000 gallons per acre daily. Owing to the fact that the Worcester sewage is often slightly acid, the results obtained by these beds have not, of course, been as good as would have been the case if the sewage was alkaline. Nevertheless, they add very materially to the efficiency of the plant. Mechanical Straining of Sewage. — In the process just described a large body of sludge is formed, this sludge consisting of the precipitated matters, chemicals and water — that is, it consists of about five to ten per cent, of mineral and organic matter, mixed with ninety to ninety- five per cent, of liquid. By filter-pressing the sludge can be further freed from the liquid until the weight of water and that of solid matter are about equal — that is, fifty percent, of each. This is expensive, however. This fact being recognized, experiments were early inaugurated at the Lawrence experiment station, looking toward some method of freeing sewage so thoroughly from the organic matter in suspension in it, that this matter would contain but a small percentage of water; that is, investigations were made looking toward producing high rates of filtra- tion through sand filters by removing the matters in sus- pension in sewage as well as or better than by chemical precipitation, and at as low or lower cost per one million gallons of sewage treated. These experiments seemed to indicate that coke strainers could be constructed which would accomplish this result. Accordingly, in 1894 a coke strainer was put into operation, containing six inches in depth of coke " breeze. " This breeze is the screenings from commercial coke. Strainers of this sort and of a varying depth were kept in operation for seven or eight " 140 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Sewerage and Sew- age Disposal. years, and resulted in removing from the applied sewage nearly as much organic matter as is removed by chemi- cal precipitation. The organic matter, moreover, re- moved in this way is left in a semi-solid mass upon the surface of the strainer or in the upper layers of coke, and can be easily removed, together with some of the coke, if necessary, when the strainer becomes clogged on ac- count of its accumulation, and subsequently dried and burned. That is to say, instead of having the suspended matters in the sewage left in the bottom of a tank mixed with a large volume of water— so large, in fact, that it forms ninety -five per cent, by weight of this concentrated sewage — we have these matters practically freed from water. Such strainers were operated at Lawrence at rates vary- ing from 1,000,000 to 2,000,000 gallons per acre daily. A strainer constructed in 1895 was continued in operation for three years, and during this period the amount of coke removed from it amounted to one inch in depth for each 16,400,000 gallons of sewage strained. It was found later, however, that with a slightly coarser grade of coke as good a removal of organic matter from the sewage could be obtained and with an expenditure of not more than half as much coke as the figures given. As a result of straining through coke, about forty per cent, of the total organic matter in the sewage can be removed, and about sixty per cent, of the organic matters in suspen- sion, varying, of course, with the different grades of sew- age. The resulting effluent from a coke strainer can, of course, be purified at a rate of filtration much greater than can be attained with a sand filter receiving un- treated sewage. At Lawrence a filter receiving strained sewage was continued in operation for a number of years at a rate approximating 300,000 gallons per acre per day, and the average effluent was about as follows, showing good nitrification and purification : Effluent of Sand Filter Parts per 100,000. Color 0.1300 Ammonia- Free 0145 Albuminoid 020T Chlorine 7.0800 Nitrogen as -Nitrates.... 2.3800 Nitrites 0001 Oxygen consumed 2300 Bacteria, per cubic cen- timetre 85.0000 A purification plant of this description has recently been constructed in the town of Gardner, Mass., where the sewage is first passed through a coke strainer with an area of one-half acre, and then to sand filter beds. Strainers of fine anthracite coal in operation at the exper- iment station have of late done better work upon an ex- perimental scale than coke filters. Filters of Coarse Material at Sapid Rates of Filtration. — Sedimentation, chemical precipitation, and straining are not, of course, in the true sense proper sewage purifi- cation. They are but preliminary methods taken to re- move and concentrate a certain amount of the organic matter in sewage, and thus make it possible to filter the main volume at high rates upon sand or other filters. It is only in fortunate localities, however, that sand filters can be constructed at a low cost. In New England in most instances sandy areas are available. Throughout a large section of this country, however, areas of sand are not to be found, and sewage filters must be built on dif- ferent lines. This is also the condition of affairs in Eng- land. Because of this, elaborate studies and experiments have been made of late years upon other means of puri- fying sewage than by sand filtration ; all these methods having, of course, as their main feature the possibility of purifying large volumes of sewage upon relatively small areas. Sand filters are comparatively inexpensive of construction, costing in New England not more than from a few hundred to four or five thousand dollars per acre, according to the locality in which they are built and other conditions. All high-rate filters, however, are of necessity constructed of material, the expense of gath- ering which together or of preparing it for use varies greatly, and in some instances exceeds the cost of a like area of sand filter beds. Of the first attempts upon filtering sewage at high rates, the passage of this sewage through aerated gravel or broken stone filters, with nitrification aided by a cur- rent of air forced into the filters, appeared to be the most interesting and practical. Such filters were operated at the Lawrence experiment station as early as 189y, and at experimental plants in other places soon after this date. At Lawrence average rates of 500,000 gallons per acre per day were obtained by this method, covering a period of five years, and good nitrification occurred in the filters, the sewage being applied to these filters in small doses at frequent intervals. The effluents of the filters, however, contained much organic matter in suspension and in so- lution, and the purification obtained was considered only preliminary to sand filtration, or, in other words, it was simply a method for increasing the rate at which sand filters could be satisfactorily operated, but with an idea of destroying, more effectively than could be done by chem-- ical precipitation or coke straining, the organic matters in suspension in the sewage. The highest average rate ob- tained at the station by this combination of aerated gravel filters and sand filters was 250,000 gallons per acre daily. Owing to the grade of gravel used and the lack of proper underdrainage, these filters clogged badly from time to time, necessitating the removal of filtering material, washing, and replacing. The sand filter also became badly clogged from time to time, necessitating the re- moval of surface sand. The cost of aeration by means of a forced current of air was considerable. Later stud- ies at Lawrence, moreover, have shown that the method of filtration and aeration followed in the gravel filters, although causing nitrification and thus partially purify- ing the sewage, undoubtedly rendered the organic mat- ters coming through these filters in suspensiou iu their effluents of a more stable, less easily decomposed nature than when applied in the sewage to the filters. For this reason, when these effluents were applied to sand filters, although the liquid passed below the sand readily and was well purified, these stable matters, instead of being readily passed into solution and nitrified by bacterial action, accumulated within the upper layers of the sand. Disposal plants based upon this method of procedure are, however, in operation in several places in this country with more or less success. Contact Filters. — Contact filters are sewage filters con- structed of any coarse material such as coke, cinders, slag, broken stone, gravel, broken bricks, etc. The method of operating these filters is to close the gate at the outlet of their underdrains, gradually fill the open space of the filter with sewage, allow a period of stand- ing full, then drain, rest for a more or less prolonged period, and again fill. In this manner the entire depth of the filter is brought into contact with the sewage ap- plied each day; that is to say, the entire open space of the filter is filled with sewage daily or even several times daily, and a high rate of filtration obtained. It is evi- dent that filters constructed of these materials and oper- ated in the way outlined cannot produce the results given by good sand filters; in other words, they are not good strainers, and the sewage passes through them too quickly for prolonged bacterial action to occur. Nevertheless, very satisfactory purification results can be obtained by their use, especially if the system of beds is so constructed that double contact of the sewage is given — that is, a system of beds in two sets, all sewage passing through two filters. In operating these filters the method of filling may be continuous or intermittent; that is to say, the sewage may be allowed to pass into the filter continuously until the entire open space is filled from the underdrains to the surface, or the sewage may be run in at frequent inter- vals. When the latter plan is followed and the sewage is well distributed, the method introduces more air into the pores of the filter than the continuous method, and better purification ensues. When the effluent flows from the filter, air is drawn into the filter again and fills the open space. It is evident that, if the action of the bac- teria upon the sewage in the filter is to be that of oxida- 141 Sewerage and Sew- age Disposal. REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. tion, the sewage should be withdrawn some time before the exhaustion of this oxygen occurs. When the filter is emptied, the oxygen drawn in causes a partial oxida- tion of the organic matter left within the filtering ma- terial, nitrification ensues, and we have a filter really working all the time, although flooded but a portion of the time. If the filter is constructed of rough material, such as cinders, coke, slag, etc., much organic matter is strained out from the applied sewage by being caught on this rough material, to remain in the filter and to become oxidized and nitrified when the filter is empty. Experi- ments with this class of filters were first made in Eng- land. Long-continued investigations have been made at the Lawrence experiment station studying this class of filter. Filters of different materials have been in operation, dif- ferent methods of flooding have been followed, and double contact has been compared with single contact. These studies have shown that the best results can be ob- tained with filters constructed of rough material, such as cinders and coke, that in such filters, when well operated, good nitrification occurs, and that fairly stable effluents are obtained. With filters of broken stone much poorer results are obtained. The rates of filtration followed have reached one million gallons per acre per day with filters of coke five feet in depth, and rates fully as great as this with filters of broken stone. In all these filters there is a tendency for the open space to become clogged more or less with the matters removed from the sewage, thus decreasing the rate of operation, and the prevention of this is the most serious problem presented in the satisfactory and permanent operation of contact filters. In fact, it is quite generally recognized at the present time that, if filters of rough material are to be used successfully in this way for any long period, a larger portion of the matters in suspension in the sewage must be removed as a pre- liminary to filtration. In the life of filters of this nature, but constructed of smooth material, this preliminary treatment is not so essential, as the material in the filter can be so graded and the underdrains left so open that much of this matter will pass from the top to the bottom of the filter and flow out from the underdrains. Such filters of smooth material, however, do not, as has been said, give as good results as the filters of rough material. Contact filters are being adopted and constructed in many places, especially in England. At Manchester, England, a plant for the purification of 30,000,000 gal- lons of sewage per day upon contact filters is now being built, the sewage first being treated in septic tanks which will be spoken of later. To show the purification results obtained by this manner of filtration, the following figures are quoted, giving the average analyses of the effluents of two coke contact filters at Lawrence, operated during 1901 at rates of 910,000 and 850,000 gallons respectively. To the first filter sewage was applied which had first been passed through a coke strainer, and to the second filter sewage just as pumped from the sewer. Table V.— Parts per 100,000. Filter No. 1. Filter No. 2. Color 0.5200 1.6400 .1716 .1238 .0478 11.4600 1.340O .0197 1.0500 131,500 0.5500 1.7200 .1842 .1250 .0592 10.1300 .8900 .0096 Ammonia- Albuminoid — Total Nitrogen as— Nitrites Bacteria per cubic centimetre 397,000 The effluents here averaged are somewhat better than can be obtained, generally speaking, by contact filtration. The purity of these effluents, however, does not compare favorably with those which can be obtained by sand fil- tration. The organic matter present in them is, never- theless, often oxidized to a more or less stable condition, thus rendering them well enough purified to run to waste at many places. Septic Tanks. — A septic tank is simply a brick or concrete tank, covered or uncovered, through which sew- age passes slowly, allowing time for sedimentation and for the action of those bacteria which disintegrate, hy- drolize, and by this means destroy or change organic matter by passing it into solution in the liquid or causing it to escape into the air in the form of gas. On a previ- ous page a statement has been made regarding the differ- ence between fresh and stale sewage. To carry on even further the bacterial action causing this change is the theory of the septic tank treatment. In many instances, however, of so-called septic tanks, the sewage when en- tering is so fresh and the period allowed in the tank so short that little more occurs toward changing the sewage than that which occurs when the sewage passes through a considerable length of sewer before reaching the filtration area. To explain the action of the tank in other words, we can say that, when oxygen is exhausted from sewage, bacterial life continues active and putrefaction ensues, following the process of decomposition, which occurs in the presence of oxygen. All of the organic matter in the effluent from a septic tank is supposed to be changed by the action of the bacteria to a condition in which it is more easily- oxidized by the aerobic bacteria in sand or other filters. While several claims to the first installation of a tank of this kind have appeared, it was in modern times and under modern studies probably first put into operation in Exeter, England, and soon adopted in other places in that country. Its success or failure as an addition to a sewage disposal or purification system appears to depend largely upon the nature of the sewage to be treated. It is evident from long-continued experiments in Lawrence and elsewhere, that with some sewages passage through the tank is of undoubted advantage in connection with the disposal of sludge, and that the sewage is as easily or more easily purified than without the tank action. Other experiments at Lawrence have shown that there is danger, in the treatment of some sewages in the tank, of so oversepticizing them, so to speak,— that is, of carrying the work of the anaerobic bacteria to such an extent — that the effluent of the tank can be filtered only with considerable difficulty and after good aeration. A small tank has been in operation for five years at the Lawrence experiment station, treating the sewage pumped there, and after these years of use the accumulated sludge within the tank amounts to about thirty per cent, of the tank capacity, the tank not having been cleaned out during the course of the experiment ; and further than this, the efflu- ent of this tank has contained only about one-half as much crude organic matter as the sewage entering. The time of passage of the sewage through the tank has aver- aged about sixteen hours. At a filtration area in Massa- chusetts a tank was continued in operation for several years, and the sewage reaching this area was really more difficult to filter after treatment in the tank than before. The reason was that the sewage was very rotten when entering the tank, and when issuing from it was of a character which seemed to retard nitrification within the filter, unless thoroughly aerated preliminary to filtration. Table VI.-Parts per 100,000. Septic sewage. Sand niter. Coke filter. Rate— gallons per acre dally 4.5200 .4300 .2700 .1600 11.2500 2.8566 1,020,000 300,000 0.7867 .0807 10.4800 2.9200 .0046 .6900 69,000 800,000 1.4021 .1480 Ammonia- Albuminoid— 11.1500 1.1500 .0093 1.0500 221,000 Nitrogen as— Bacteria per cubic centimetre 142 REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. Sewerage ana Sew- age Disposal. The effluent from the septic tank at the Lawrence sta- tion has been applied for the past five years to two ex- perimental filters, one of these being an intermittent sand filter and the other a coke contact filter. High rates of filtration have been maintained with each filter. During 1902 the rates and the average analysis of the septic sew- age applied to and the effluents from these filters were as shown in the preceding table. At Manchester, England, very extensive experiments were carried on for two or three years, investigating this process. Tanks with a capacity of 500,000 gallons per Say were operated, both covered and closed tanks being used, with little difference in the results obtained, and the city of Manchester is now building a sewage disposal system whereby the sewage will first be treated in septic tanks and then upon double contact filters. At this city in 1900 the volume of sewage to be disposed of reached 30,000,000 gallons per day. From the operation of their experimental tanks it was estimated there that it would be fair to assume that fully thirty -five per cent, of the sludge would not become liquefied in the tanks, but would have to be removed from time to time. That is to say, where they were in 1899 carrying 237,000 tons of wet sludge to sea per year, it was estimated that only about 75,000 tons would have to be carried to sea after the con- struction of the system; the remaining organic matter being disposed of by bacterial action in the tanks and on the filters. At "Worcester, Mass., this method of treatment has been experimented with for several years, a tank of 350,- 000 gallons capacity having been used. Through this, sewage has been made to flow at a rate varying from 300,000 to 500,000 gallons per day. The sewage at Worcester is generally acid, but this has not interfered entirely with the tank action, as about twenty -five per cent, of the total solid matter has generally been removed by the tank. The odor from this tank has been very con- siderable, and also from the beds when this sewage has been applied to them. Plainfield, N. J., among other places, has recently adopted this system of sewage disposal. This is a city of about 16,000 people, and has the so-called separate sj r s- tem of sewers. It formerly disposed of its sewage on sand filters, but these were not particularly successful owing to the extreme fineness of the sand. Hence a change was made. Two septic tanks have been con- structed, fifty feet wide, one hundred feet long, and six feet deep, both being under one roof. The sewage, after it passes from these tanks, goes to a double set of contact filter beds. The average flow of sewage per day at the present time is about 800,000 gallons, and it reaches the disposal plant through a fifteen-inch pipe. At this place it enters a small influent chamber, where the flow may be diverted to either tank. The sewage enters the tanks about two feet above their floor level. In front of the inlets to the tanks are baffle walls, to deflect the flow of sewage and distribute it evenly across the whole width of each tank. The sewage flows from outlet open- ings, twelve in number in each tank, placed below the surface of the sewage and above the floor of the tank. In leaving the tanks the sewage passes upward over a weir into a channel to the first set of contact beds. Air and light are excluded from the septic tank, but the sewage is supposed to be aerated after passing from the tank by flowing into and through a channel extend- ing the full length of each tank. The gate-house and roof over the septic tanks are of wood, with tar and gravel covering, all the remainder of the construction' of the tank and weir being of stone, brick, or concrete. The contact beds are in two sets of four each, the first set being 5.42 feet above the level of the second set. Each bed is ninety -two feet wide, one hundred and six feet long, and five feet deep. On the concrete floor of each bed fourteen lines of four-inch horseshoe tiles are laid, radiated from the gate-chamber, and coarse stone is spread beneath and over them six inches deep. The first set of beds contain, above this coarse stone, three and one-half feet in depth of trap rock, the pieces of rock varying in size from one-fourth to one and one-half inches in diameter. The second set of beds are of prac- tically the same depth, but slag and cinders are used as filtering materials instead of the broken stone. Distribu- tion pipes are laid in the upper foot of the material, through which the sewage is distributed over the surface of the beds. The sewage runs continuously from the septic tank through a twelve-inch pipe, built in the top and middle wall of the gate-chamber at the intersection of the division walls. Here it is diverted by wooden gates to each of the four beds in succession. After one bed is filled the sewage is turned on to the next, and so on ; the height of the sewage in the beds being indicated by tell-tale balls above the roof of the gate-chambers. The sewage remains in each bed an hour or more, is drawn off through a sluice-gate and passes through a pipe to the gate-chamber of the second set of beds, from which it is discharged, after a period of contact, into a brook. Each bed is at rest an hour or more between fillings. Sludge can be drawn from the tanks through eight-inch pipes to sand filters. In a year's operation of this system it was necessary to remove sludge from the septic tanks several times. The price of construction of this system of disposal is said to have been about $40,000. Intermittent Continuous Filtration. — In the continua- tion of studies upon rapid methods suitable for the puri- fication of sewage, filters of coarse material have been constructed, through which sewage is passed in a prac- tically continuous stream. The coarseness of the mate- rial used in these filters is so great, however, and the rate of application of the sewage to them so regulated, that the surface of the filter is always practically free from sewage, and a large portion of the open space in the filter- ing material is always filled with air. Such filters may be constructed either of rough material such as coke, slag or cinders, or of smooth material, such as coarse gravel or broken stone. By the method of operation the sewage applied passes in thin streams or layers over the filtering material, and is in contact with air from its entrance at the surface of the filter until it passes away in the under- drains. "With a filtering material of such a c6arse nature, operated under conditions which assure an abundance of air within the filter, wonderful activity of the oxidizing and nitrifying bacteria is induced, and the production of nitrates is exceedingly rapid. Filters constructed in this manner, containing from eight to ten feet in depth of filter- ing material, can be operated, on an experimental scale at least, at rates approximating two million gallons per acre daily, and produce a highly nitrified effluent. Much of the organic matter in suspension in the sewage when it enters these filters passes away in suspension in their effluents, but in a very different and inoffensive condition from that in which it exists when applied to the filters. That is, if the filter is well constructed and properly operated, a large portion of this matter adheres for a considerable period to the filtering material throughout the entire depth of the filter, and its more easily decom- posed constituents are either passed into solution, or dis- appear as gas, while the remainder is oxidized to a more stable form. Effluents of successful filters of this class contain organic matter in such a stable form that they are little subject to putrefaction even under adverse con- ditions, except after a considerable interval, and more often than otherwise they improve in character after issu- ing from the filter. Their steady improvement is assured if they run into a considerable body of water containing free oxygen. Filters of this class were first put into oper- ation at the Lawrence experiment station in 1899, and have since been studied quite extensively there. Studies upon their operation and the results produced by them have also been carried on in England of late years upon a considerably larger scale than at the experiment station. They have not as yet, however, been installed on any con- siderable scale for the practical treatment of the sewage of a town or city. Such a filter was operated at Lawrence during 1903 at a rate, at times, of 2,250,000 gallons per acre per day, and produced an effluent often turbid, but 143 Sex. Sex. REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. always well nitrified and fairly stable. The average analysis of this effluent is shown in the following table, of many analyses made during the year: TABLE VII.— PARTS PER 100,030. Rate— gallons per acre daily 1,820,000 Color 5 '"° A "Z°™~ l.T«0 A Ibuminolcl „■*??? Chlorine 8 - blu0 Nitrogen as - _„_„ Nitiates 2-7600 Nitrites -OU'l Oxygen consumed 7 . nn Bacteria per cubic centimetre 40,000 Resume. — In the preceding pages nine methods of sew- age disposal or purification have been described, covering the most important methods in use at the present time. They include those methods by which sewage is purified by natural means— that is, by bacteria and air— and which have promise of such developments in the future as adequately to cover all sewage purification problems. The methods are as follows: 1. Disposal by dilution. 2. Sewage farming or irrigation. 3. Filtration through intermittent sand filters. 4. Chemical precipitation, followed by filtration. 5. Mechanical straining, followed by filtration. 6. Filtration through gravel or other filters of coarse material, with forced aeration. 7. Coutact filters. 8. Septic tank treatment, followed by filtration. 9. Intermittent continuous filtration. Summarizing these methods, it can be said that dis- posal by dilution is extensively practised and entirely satisfactory at such places as those mentioned in the pre- vious text. Sewage farming is successful in many places, espe- cially with a concentrated English or European sewage. Filtration through intermittent filters of sand or other fine material is a process which is already extensively used and is certainly destined to be used very largely in the future wherever such filters can be built at a reasonable expense. They are entirely successful wherever used, if the material of which the beds are constructed is suit- able, and if such beds are properly operated. Where a large amount of sewage must be taken care of upon a small area, or where some clarification must be made before sewage is disposed of by dilution, chem- ical precipitation is of undoubted value and will be used for many years in meeting such problems. Straining sewage through coke or other materials of a like nature is undoubtedly successful on a small scale, and the future will show "whether it can be applied to larger problems. Forced aeration and filtration through gravel is hardly entitled to serious consideration in this connection, but as it was really the first step in the various processes of rapid filtration, it has been included in the previous text. It can undoubtedly be made practical and of use where the volume of sewage to be purified is small, and where cost is a secondary consideration. The use of contact filters will increase undoubtedly at places where sand filters cannot be easily or inexpensively constructed. If they are properly built and properly op- erated, good results can be obtained by their use. Septic tank treatment is also a proved success in some cases, and will undoubtedly be used much in the future. It must never be considered, however, as it is sometimes now considered by those ignorant, of the subject, that the septic tank treatment is a purification. It is simply a clarification, and a preliminary treatment whereby sludge may be destroyed and the sewage may be so changed that either purification is made more easy by subsequent filtra- tion, or the rate of filtration made greater than could be secured without this treatment. Intermittent continuous filters seem to have very much of promise in them, and they will undoubtedly be adopted more and more at places where sewage must be disposed of upou a small area and where the climate does not in- terfere with their efficient operation. II. W. Clark. SEX. — In the life history of nearly every multicellular organism there is a time when a new germ (oOsperniium, or zygote) is formed by the union of two cells (gametes) of different aspect. The larger, less mobile of the two cells, is the macrogamete, egg, or ovum (q. v.), and the smaller more active one is the microgamete, spermatozoon (g.v.) or its equivalent. The ability to produce a macro- or microgamete constitutes the essential distinction of sex. The individual which produces the latter is said to be of the male sex, the individual producing the former is said to be of the female sex. In most of the higher plants and in a few of the lower animals both sexes are included in a single individual, which is then said to be hermaphro- dite. The union of dissimilar gametes is the essential feature of sexual reproduction (see Impregnation). In many of the uuicellular animals, Protozoa, there is a temporary union, or conjugation, of similar gametes, dur- ing which there is an interchange of part of the nuclear substance. In other Protozoa the gametes are of differ- ent size and the union is complete and permanent. Thus in these lowly forms we see foreshadowed the sexual process of the higher organisms. If our definition of sex be correct, it follows that the quality of sex cannot be an attribute of the gametes, but only of the parent organism, except in so far as the sex of the offspring may be determined by some characteris- tic of one or both of the gametes. This view is borne out by what is known of the history of the germ cells, which has been shown elsewhere to be identical in all essential features in the two sexes (see Reduction Division). The differences between the gametes of the male and those of the female are confined to the cytoplasmic structures, and are associated with a physiological division of labor; the cytoplasm of the egg being more or less laden with food yolk and unprovided with locomotor apparatus, while the spermatozoon has practically all of its cytoplasm modified into a locomotor apparatus, by means of which it may actively seek the egg. This explanation is not in accordance, however, with the views of Geddes and Thomson, who see in the visible difference between egg and sperm evidence of the same differentiation of sex that is found in the adult. They regard sex as a quality of protoplasm. It i3 for them a question of metabolism. In the female the anabolic processes are predominant, while the katabolic processes are predominant in the male. These characteristics are passed on to the eggs and spermatozoa respectively, and fertilization "restores the normal balance and rhythm of cellular life.'' It is difficult to follow the physiology of this concep- tion of sex, for, if the male is predominantly katabolic, one would think it might be hard for him to grow ; one might almost expect him to shrink. Havelock Ellis (1894) has gathered the published data in regard to the differences in metabolism of men and women, and he finds differences in certain phases, but the general result is iuconclusive. Thus, men have a larger percentage of haemoglobin in the blood and greater lung capacity in proportion to stature; but, on the other hand, women have a higher pulse rate. It is very probable that in the period of early maturity in women there is less katabolic activity than in men as is shown by the greater tendency to store up fat. But, if the words mean anything, a pre- dominant condition of katabolism is inconsistent with in- crease of weight or with life itself beyond a very limited period, and therefore can hardly be accepted as the es- sential feature of "maleness." We may follow Ellis in dividing the characteristics that distinguish the sexes into primary, secondary, and tertiary. The primary characteristics are those asso- ciated with the organs concerned in the production and union of the gametes. And these organs may be divided again into the essential and the accessory reproductive organs. The former are the gonads, called ovary and testis in female and male animals respectively. In low 144 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Sex. Sex. forms, like the jelly-fishes, there are no other reproduc- tive organs. But we need to go very little higher in the scale to find developed accessory organs that assist in the discharge and union of the gametes. Such are the ovi- ducts, the vasa deferentia, and the appendages of these organs. Morphologically these tubes may be modified nephridea, or they may be newly developed structures. In all strictly terrestrial animals and in many of the higher groups of aquatic forms fertilization takes place within the oviduct. This is associated with a marked structural differentiation of the sexes. The male is usually pro- vided with a special organ for the introduction of the spermatozoa. This may be a prolongation of the sexual orifice, forming a penis, or, as in the rays and higher Crustacea, it may be in part a modified limb. In the fe- male, on the other hand, the oviduct is either provided with glands to secrete a protective covering for the egg, or is modified to shelter the developing embryo, or even, as in the placental mammals, to nourish it during its fcetal life. The secondary sexual characters are those that clearly distinguish the sexes without being directly concerned in the reproductive function. Among these characters we may distinguish clasping organs, weapons, ornamenta- tion, voice, and appliances for the shelter or nutrition of the offspring. In a large number of animals, especially among the Crustacea and insects, there are to be found special modifications of one or more limbs of the males which serve to hold the female in firm embrace during coitus. Many males are provided with weapons, as tusks, horns, spurs, or the like, which are employed in fighting with other males for the possession of the fe- males. Often the males alone are provided with such weapons, and when they are possessed by both sexes, they may differ in the two sexes. Thus the cow has long, pointed horns adapted for defense against carniv- orous enemies, while the bull has shorter, thicker horns, probably more useful for fighting with rivals. In some cases structures that probably arose as weapons are now developed as ornaments. The most notable ex- amples of this are the antlers of the deer family. In most cases, however, the ornamentation has arisen inde- pendently of the weapons, and consists of the most varied forms of coloring and modification of structure. Orna- mental secondary sexual characters are found widely dis- tributed among the insects, amphibia, reptiles, birds, and mammals. They are especially conspicuous among the birds. They are usually possessed by the adult males only, and reach their highest state of perfection during the mating season. After this season the deer shed their antlers, and many male birds, like the bobolink, exchange their bright plumes for the sober protective coloring of the female. This exuberance of growth and coloring in the males, together with the song of male birds, and other instances of greater activity, like the superior eagerness of the male in courtship, are taken by Geddes and Thom- son as evidence for their conception of maleness as a pre- ponderance of katabolic activity. But they leave out of consideration the fact that these conditions are not always characteristic of the male sex. In the species of phala- rope— birds not uncommon on our shores — the female is the more brightly colored, the more pugnacious, and more ardent in courtship; in short, she has all charac- teristics usually found in a male, except that she lays eggs. The male, on the other hand, is relatively dull col- ored, is courted by the female, incubates the eggs, and takes entire care of the young. The characters that we are considering are called orna- mental, not because they appear beautiful to us — often they are quite the contrary — but because, according to Darwin's theory of sexual selection, they are supposed to have been developed through the choice, conscious or un- conscious, of the courted sex (see Evolution). In man we find ornamental secondary sexual characters in both sexes, which would seem to indicate that the courting is not all done by one sex. The chief of these characters in men is the beard. While women have longer hair on top of the head, and this is associated Vol. VII.— 10 typically with an entire absence of visible hair on other parts of the body, except on the axilla and pubes. The layer of subcutaneous fat that develops in young women upon reaching maturity, and gives them the characteris- tic rounded contours of that period, may have become a fixed character of the species by the action of natural selection, owing to its value as a provision for the nutri- tion of prospective offspring; but, at any rate, it now forms one of the chief ornaments of women. Sexual differences in the voice or in the method of using it are common, as every one knows, iu amphibia, birds, and mammals. Witness the piping of the frogs, the song of birds, and the deep voice of men. Usually the modification of the voice is found in the males, and first appears, as in man, at the beginning of maturity. In fact, it is a general rule that when the male possesses special weapons, ornaments, or peculiarities of voice, these characteristics are not developed until about the time of the first ripening of the spermatozoa, and the immature males resemble the females. For this reason it has been inferred that the female, at least so far as these characters are concerned, represents a more primi- tive type than the adult male. Devices for sheltering eggs or young are developed after different patterns in various groups of the animal kingdom, and they are usually confined to the females. Thus in most species of Crustacea the female is provided with some means of carrying the eggs until they hatch. The female marsupials have a fold of the skin forming a pouch, in which the imperfectly developed young are placed at birth and are carried there until they are able to run about. The most characteristic organs of the mammalia and the ones from which the group has re- ceived its name, the rnammne, or milk glands, are pos- sessed by the females of all species from monotremes to man. While functional only in the females, these organs are present in a rudimentary condition in the males also. Their importance as a means of rearing the young is so great that it has been questioned as to whether they should not be regarded as primary rather than secondary sexual organs. That they are essentially secondary, how- ever, is shown by the practices of civilized women, who have largely relegated them to the position of orna- ments — to the detriment of the best races of the human species. In addition to the well-marked secondary sexual char- acters that distinguish males and females, there are other usually slight differences that Ellis classifies as tertiary sexual characters. We know very little in regard to these differences in the sexes of the other animals, but, thanks to Ellis, we have in his book, "Man and Woman " (1894), a very interesting and complete summary of these characters, anatomical, physiological, and psychical, in men and women. It would be impossible to summarize even his summary in the limits of this article. We can notice only a few of his conclusions and must refer the reader to the book for more. Among the anatomical differences women show a greater youthfulness of physical type, as is common among females generally ; but they show another ana- tomical peculiarity not found in other female mammals, and that is an enlargement of the pelvis. This, in the higher races of men, might be regarded as a secondary sexual character. A study of the brain and of the intel- lectual process in men and women gives the impression that the observed intellectual differences may be as much due to differences of training as to any innate differences between the sexes. In their senses women appear to be less discriminating, but more irritable, and in their emo- tions they show a greater affectability. Ellis thinks that women are more variable than men, but that this is true for all characters is denied by Pearson. It is a general rule that in most species the two sexes are approximately equal in number of individuals, but in a few forms in which parthenogenesis is common there may be a large preponderance of females. From the records of 59,350,000 births in European countries Oes- terlen (1874) calculated that the normal proportion of 145 Sex. Sexual Organs. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. boys to girls is 106.3 to 100, and in the single countries the proportion of boys varied only between 105.2 and 107.2 The following statistics of the numerical proportion of the sexes in other animals were collected by Darwin ("Descent of Man," Amer. ed., vol. i., pp. 293-307): English race-horses Greyhounds English and Scotch sheep . . Cattle Fowls (pure Cochins) Lepidoptera, various specie; Number of 25,560 6,878 59,650 982 1,001 1,695 Proportion of males to 100 females. 99.7 110.1 97.7 94.4 94.7 122.7 These figures are all taken from records of births ex- cept in the case of the sheep, in which the sex was re- corded at the time of castration, and in the case of the lepidoptera, in which the sex of the imagos was recorded after emergence from the chrysalis. In the pigeons, which have two young in a brood, there is usually one of each sex, but occasionally both will be males, more rarely both females. The question as to the factors that determine whether any given individual shall be a male or a female has excited the greatest interest since early times, and it is probable that there is no subject within the domain of biology on which so much nonsense has been written. According to Beard, it has been estimated that there are over five hundred theories, or rather hypotheses, of sex ; and still we know practically nothing as to the cause of the determination of sex in the individual. It is mani- festly impossible to review any considerable number of these hypotheses within the limits of the present article, and we will confine our attention to a few that deserve special attention because they are either very recent or are founded on experimental evidence. Waldeyer (1903) divides the hypotheses into three groups which he calls progamous, syngamons, and epi- gamous. 1. According to the progamous theories the sex of the future individual is determined before the fer- tilization of the egg from which it is to develop, (a) According to some authors the differentiation takes place in the spermatozoon, (b) while others think that it is in the unfertilized egg that this occurs. 2. Thesyngamous theories hold that the sex of the embyro is determined at the time of fertilization, while (3) the supporters of the epigamous theories hold that the zygote and the embryo in its early stages are sexually indifferent, and that the sex is determined by external factors acting upon the embryo during its development. There is evidence for the progamous determination of sex in the fact that some animals like the rotifer, Hydati- na; the worm, Dinophilus; and the plant louse, Phil- loxera, produce two forms of eggs, the larger of which always develop into females, and the smaller into males. In Dinophilus the eggs are fertilized, but in the other two they are parthenogenetic, and thus in them there can be no question of the influence of spermatozoa. Each female of Hydatina lays normally but one kind of egg, and Nussbaum has shown that if females are well fed from the time of hatching they will produce exclu- sively female eggs; if poorly fed, male eggs. Beard (1902) has attempted to formulate a general theory of sex based on the idea of two kinds of eggs. He thinks that sex is determined in the oogonia or in the synapsis stage of the oocytes (see Reduction Division), and denies that the spermatozoa have anything to do with the determination of sex. The basis for this view is chiefly his discovery that in very young embryos of the skate, Raja batis, the number of primary germ cells in females is double that in males. His argument, however, is far from clear, and is by no means convinc- ing. The contrary view, that it is the spermatozoon that determines sex, is expressed by McClung (1902). In cer- tain insects there is found in the primary spermatocytes an accessory chromosome that behaves differently from the others during synapsis. It divides but once during the maturation divisions, and the halves are distributed to two of the spermatids only (x, Fig. 3941, in article Re- duction Division). Thus there are formed two kinds of spermatozoa in equal numbers, and McClung suggests that the ones containing the accessory chromosome are male and the others female, the accessory chromosome not being found in female germ cells. While this hypoth- esis may apply to the insects in question, it is inappli- cable to the forms already mentioned in which the sper- matozoa can have no effect. Allied to these theories is the view that the determina- tion of sex is a phenomenon of heredity. This is not a new idea, but it has been brought out recently again by two authors. Orschansky (1903) distinguishes two types of families — in one a majority of the children are male, in the other female ; and he tries to show that the other characters of the parents, especially predisposition to disease, are dis- tributed among the children in the same way that the sexual characters are. But his conclusions are not ob- tained by precise methods, although he deals with large numbers. Castle (1903) attempts to explain the determination of sex on Mendel's theory of heredity (see Reversion). His argument is briefly this: (1) Sex is an attribute of every gamete, whether egg or spermatozoon, and is not con- trolled by environment. It is inherited according to Mendel's law. So the formula for the second generation should be M + 2MF+ F. (2) But we do not get herma- phrodites usually, nor do we get pure males or females. The characteristics of one sex are always latent in the other. So the actual formula is M (F) + F(M ). (3) To explain this it is necessary to assume that a gamete of one sex can unite in fertilization only with a gamete of the opposite sex. (4) But one sex must be dominant and the other recessive or we should get hermaphrodites. It cannot be that one sex is always dominant. So it is nec- essary to assume that " Dominance, in dioecious species, is possessed sometimes bj' the male character, sometimes by the female." In other words, it is assumed that some organisms are male and some are female, which is the fact that we were trying to explain, — a good example of circular reasoning, and one not likely to lead us to a definite conclusion. The only experimental evidence of the syngamous determination of sex is furnished by the bee. As was first shown by Dzieron, whose conclusions have been fully confirmed by Weismann and Petrunkewitsch, the question as to whether a given egg shall develop into a male or a female is determined by its being unfertilized or fertilized. The fertilized eggs develop into fe- males, the unfertilized into males; another case in which McClung's theory would not apply. Among the theories of the syngamous determination of sex are to be placed those in regard to the effect of the relative age of the parents or of the gametes, the relative sexual vigor of the parents, etc. Statistics have been gathered to show the effect of these factors. But they show at most a slight change from the normal numerical proportion of the sexes, andO. Schultze (1902) concludes from a scries of experiments on mice, extending over two years, that these factors have no effect in the determina- tion of sex. Included in this group is also the once much-heralded theory of Schenk. He thought that the sex of the zygote depends on the relative vigor of the gametes, and sought to influence this by improving the metabolic condition of the mother. His results were ob- tained from experiments on two or three women only, too few to afford a basis for sound generalization. There is considerable evidence for the epigamous de- termination of sex by the state of nutrition of the embryo or larva. One of the earliest experimenters in this field was Mrs. Mary Treat, of Philadelphia. She divided a brood of caterpillars into two lots, and during the period 146 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Sex. Sexual Organs. between the last moult and the pupa stage one lot was well fed and the other was kept on the lowest possible diet. When the imagos emerged she found in the starved lot seven ty-six males and three females, while the well-fed lot produced four males and sixty-eight females. These results were confirmed by Landois, wfio experimented on a thousand caterpillars of Vanessa ; but doubt has been thrown on these results by Poulton, who fiDds that starvation produces a much higher death rate among females than among males. Similar conclusions to those of Mrs. Treat and Landois were obtained by Yung from experiments on tadpoles. He found that normally about fifty-seven per cent, of the tadpoles developed into females. By feeding one lot with beef he raised the percentage to seventy -eight; by feeding a second lot with fish he raised the percentage still higher to eighty-one per cent. ; and by feeding with the flesh of frogs he obtained as many as ninety-two per cent, of females. But these experiments, like the others, have been criticised by Pflligerand other writers as being inexact, possible factors beside nutrition having been neglected. However, in the fresh-water polyp, Hydra, which is usually hermaphrodite, Nussbaum found that by good feeding he could stimulate the exclusive production of ovaries, and that in the ponds in the fall, when the food is becoming less, he found a greater number of males. Moreover, we know that in the plant lice sex is corre- lated with the condition of the food supply. There are a good many experiments to show that in the lower plants sex may be regulated by food in the same way. On the other hand, Strasburger holds that it is impossible to influence the sex of dioecious phanero- gams after the seed is formed from which the plant is to develop. Whatever are the influences that determine sex they act primarily upon the essential reproductive organs, which in turn form the necessary condition for the devel- opment of the secondary sex- ual characters, as is shown by the effect of castration. If the gonads are removed before maturity the appropriate sec- ondary sexual characters fail to develop, as in the familiar cases of horses, oxeD, and ca- pons. Moreover, diseases or removal of these organs after maturity affect the structure of the secondary sexual char- acters. Castration is employed sometimes by surgeons to re- duce an hypertrophied pros- tate, and in women and in hens disease or removal of the ovaries has been observed to induce a partial development of la- tent male characters. How the gonads influence the rest of the body is not known, but from analogy with the thyroid gland, it is supposed to be by means of an internal secretion. Bobert Payne Bigelow. BlBLIOGRAPHrCAL REFERENCES. posterior column Beard, J. : The Determination of Sex in Animal Development. Zool. bulbs of the vesti- Jahrb. Anat., 1903, pp. 701-764. bule Castle, W. E. : The Heredity of Sex. Bull. Mus. Comp., Zool. Harv., vol. nympnae 4U-H|/ xl., No. 4, 1903. KV; 1 ''*- Darwin, C. : Descent of Man and Se- J') jit,'.!* lection in Relation to Sex. New l'l,*Ki: York, 1872. labia WWSn Ellis, H. : Man and Woman : A Study lWW«. of Human Secondary Sexual Char- acters. London, 1894. Geddes, P., and Thomson, J. A. : The Fig. 4191 Evolutiou of Sex, revised edition. London, 1901. Henneberg, B. : Wo durch wlrd das Geschlechtsverhaltnis beim Menschen und den hoheren Tieren be- 697-721. (Hermann's einflust? Ergeb. der Anat. u. Entw., vol. vii., 1898, pp. 697-721 Hensen, V. : Physiologie der Zeuzung. Letpsic, 1881. ' Handb. d. Physiol., 6. Bd., ii. Tb.). Korschelt, E. und Heider, K. : Lehrbuch der vergleichenden Ent- wicklungsgeschlchte der WIrbellosen Thiere., Allgem. Th. Jena, 1902, pp. 377-383 and 395-396. McClung, C. E. : The Accessory Chromosome— Sex Determinant ? Biol. Bulletin, vol. iii., 1902, pp. 43-84. Oesterlen : Handbuch d. med. Statistik. Tubingen, 1874. Orschansky, J. : Die Vererbung im gesunden und krankhaften Zu- stande und die Entstehung des Geschlechts beim Menschen. Stutt- gart, 1903. Schultze, O. : Was lehren uns Beobachtung und Experiment iiber die Ursachen mannlicber und weiblieher Geschlechtsbildung bei Tieren und Pflanzen. Deut. med. Wocbensch., 1902, p. 371. Waldeyer, W. : Die Geschlechtszellen, 1903, pp. 413-41o. (Hertwig's Handb. d. verg. u. exper. Entwickelungslehre der Wirbeltiere, Lief, 10-11.) SEXUAL ORGANS, FEMALE.— The female organs of generation comprise the two genital glands or ovaries that produce the sexual elements, the two oviducts that convey them, the single uterus that protects them after impregnation, and the single vagina and vulva that serve as orgaus of copulation (see Fig. 4191). Development. — Originally the male and female organs are indistinguishable, both being developed out of an un- differentiated form. In many lower vertebrates the geni- tal gland, the oldest and primary organ, empties its products (ova, spermatozoa) directly into the peritoneal cavity, whence they pass out by means of openings in the belly wall called abdominal pores. In the next higher forms these become associated with other organs of elimi- nation and removal. Tubular canals termed nepliridia communicate with the peritoneal cavity by means of a funnel-shaped opening or nephrostome, each having also a side branch that envelops an arteriole, thus forming a glomerulus and becoming an excretory duct for urine. The nephridia are, originally, arranged metamerically and are therefore sometimes called segmental organs. This arrangement gradually disappears by the increase of the canals which come to be assembled in distinct or- UTERUS isthmus of oviduct Oviduct cavity of body isthmus of uterus cervical canal external orifice ampulla parovarium Vagina Alffi Diagrammatic Frontal Section of the Female Genital Organs passing through the Ori- fice of the Vagina. The oviduct and the ovary are lifted up. (Henle, modified by Rieffel.) gans, successively developed; the pro- nephros, or head kidney, very simple in structure, the only functional urinary organ in amphioxus, persisting through- out life in some fishes, but disappear- ing early in man, and the mesonep/i ros, primitive kidney or Wolffian body (Cas- par Friedrich Wolff, 1735-94), which appears behind the pronephros, and which likewise consists of a series of ne- phridial tubules to each of which a glomerulus is attached, and which open into a duct (segmental duct, Wolffian duct) that, in common with the intes- tine, discharges into the cloaca, a short receptacle for excreta just above the anus. In some fishes and amphibians the Wolffian body remains throughout life 147 Sexual Organs. Sexual Organs. REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. a functionally active urinary organ, and, in amphibi- ans, carries on the duplicate function of urinary or- gan and genital duct. In the higher vertebrates the - Cerv. moij. C&rv: ant. Fig. 4192.— Human Embryo during the Fifth Week. The anterior wall of the trunk has been removed : the Wolffian body exposed. (Kollmann.) Cerv. ant., moy.. post., Forebrain, midbrain, and hindbrain; l°f-b., first branchial cleft; Bg. fr., frontal process; Co., heart; Sac. pi., pulmonary diverticulum; Coel., coslom; P.ab., lateral wall of the abdomen ; M.i, rudiment of the lower ex- tremity; P.gen., genital ridge ; R.pr., Wolffian body ; Int., intes- tine ; T.Q., genital eminence ; Ex., caudal extremity. urinary function is taken on by the permanent kidney and the Wolffian body, as such, atrophies, portions of it remaining, however, as ducts for removing the sexual products. The first rudiment of the genito-urinary apparatus is the genito-urinary ridge (Fig. 4192, P.gen.), a thickened, longitudinal band of epithelium that appears in the em- -C.w/. Fig. 4193.— Wolffian Body and the Genital Gland. Human em- bryo 17 mm. long. (Kollmann.) L.dg., Suspensory ligament; G.g., genital gland; C.W., Wolffian duct; R.pr., Wolffian body, mesonephros, or primitive kidney ; Int., intestine ; A.o., umbilical artery ; At, duct of the allantois ; Oub., gubernaculum of the geni- tal gland or ligamentum genitoinguinale ; C.wf., canaliculi of the Wolffian body. bryo of the fifth week near the spine and the primitive mesentery. This gradually increases in size, assumes an oval form, and detaches itself from the body wall as the Wolffian body (Fig. 4193, M.pr.) with its excretory duct (Fig. 4193, c.w.). Close beside this duct and following the same general course. there develops a second tubule, Milller's duct (Johannes Muller, 1801-58) (Fig. 4194, M). It has a nephridial character, opening into the abdominal cavity by a nephrostome (Fig. 4194, m'), but has no glom- erulus connected with it. In the female it becomes the oviduct ; in the male it soon atrophies, only ves- tiges of it remaining. It is the Wolffian duct, however, that atrophies in the fe- male, a trace of it remain- ing as the ductus epoophori longitudinalis, and the duct of Gartner. Not all of the genito- urinary ridge goes to form the Wolffian body. A por- tion of it, along its ventral aspect, is destined to form the genital gland proper. This portion is termed the genital ridge or fold, and is covered with large-celled epithelium (germinal epi- thelium) that produces the fig. 4194. essential sexual elements, ova or spermatozoa. In mammals, the Wolffian body atrophies in large part, the genital ridge assumes an oval form and becomes either an ovary or a testis. A vestige of the upper part of the ridge becomes, in the female, the suspensory liga- ment of the ovary ; a vestige of the lower end becomes, in the male, the gubernaculum of the genital gland (liga- mentum genitoinguinale), which, in the female, becomes attached to Milller's duct where the latter crosses over it, and thus becomes divided into the ligament of the suspensory ligament Longitudinal Section through Genito-urinary Ridge of Human Female Embryo of about Fourteen Weeks (3.5 in. long) . ( Waldeyer.) o. Ovary ; e, tubes of upper part of Wolf- flan body forming the epoopbo- ron ; W, lower part of Wolffian body, forming paroophoron ; w', remnant of Wolffian duct; M, Muller's duct ; m', its fun- nel-shaped peritoneal opening or nephrostome. oviduct (Muller's duct) .. ovarian ligament round ligament .» ovary I inguinal ligament ( (gubernaculum) pelvic cavity Fig. 4195.— Scheme showing the Genesis of the Primitive Broad Ligament or Mesonephridium. From a human embryo 5.5 cm. long. ( Fredet.) Muller's duct should pass over the inguinal liga- ment. The mesonephridium stretches longitudinally from the dia- phrnghm to the inguinal region on each side of the pelvic cavity, ensheathlng the structures shown in the diagram. ovary and the round ligament of the uterus, which pass respectively from the ovary to the uterus, and thence to the groin. As the Wolffian and Milllerian ducts converge from either side toward the median line, they become united in a common cord, the genital cord, and, before reaching the cloaca, the Mtlllerian ducts blend in a single passage which, by enlargement and thickening of the walls, be- comes the uterus and the vagina. Occasional traces of the Wolffian duct are found along the sides of these or- gans, forming the so-called duct of Gartner, described by the Danish anatomist Gartner in 1822 in the sow, but previously noted in 1681 by Malpighi in the cow. 148 REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Sexual Organs. Sexual Organs. suspensory liga- 1 ment i mesosalpinx - mesovarium • mesometrium .. mesodesma teres •-- pelvic cavity Fig. 4196.— Diagram of Section of the Mesone- phridium at its Base. (Fredet.) The duct of Miiller descending into the pelvic cavity forms a primitive mesometrium. The genito-urinary ridge, like the rest of the walls of the body cavity, is covered over with peritoneum. As the Wolffian body becomes detached it is still held to the walls by a fold of peritoneum — the mesonephridium of Waldeyer, which invests both the free portions of the Wolffian and the Milllerian ducts and the upper part of the genital cord (Figs. 4195, 4196, and 4197). The meso- nephridia of opposite sides are therefore continuous with each other across the median line, and, as the Wolffian body atrophies and the uterus develops, there is thus formed the large transverse fold of peritoneum known as the broad ligaments of the uterus, which invest the re- mainsofthe Wolffian body, the ovaries, the ovi- ducts, and the up- per part of the uterus. A change in the position Of the ovary occurs, aris- ing from the dif- ference in the growth of the ovarian attach- ments and that of the .general body. This, the " descent of the ovary," is analogous to the descent of the tes- tis in the male, but is not usually so complete, because of the interpo- sition of the uterus by the attachment of the guber- naculum thereto (Fig. 4197). It places the organ in the pelvic cavity. Rarely it has been known to pro- ceed along the course of the round ligament of the uterus and reach the interior of the labium majus, the analogue of the scrotum of the male. In the female there, develop, from the deeper layers of the germinal epithelium, cells of two kinds, one of which, large, with reticular nuclei, becomes the sexual cells or ova; others, smaller and more cubical, surround the former and separate them from the invading mesodermal connective tissue. t The sexual cells form, at first, chap- let-like strings known as egg columns ov Pflilger's tu- bules (E. F. W. Pfluger, born 1829); later these are broken up, each sexual cell forming, with its investing elements, a primitive follicle or ovisac (Fig. 4198). The cloaca or common passage into which the intestine and the genito-urinary ducts discharge is at first closed from the exterior by a thin partition termed the cloacal suspensory ligament ovary oviduct ovarian ligament round ligament outline of pelvis Fig. 4197.— Diagram showing Formation of the Permanent Broad Ligament. (Fredet.) The mesodesma suspensorium (peritoneum around suspensory ligament), the mesovarium, the mesodesma teres (peritoneum around round ligament), and the mesosalpinx, which form at first a continuous fold on either side (the primitive broad ligament) are drawn together and united across the middle line (mesometrium) by the union of the ducts of Miiller. The oviduct should pass over the round ligament. membrane, extending from the rudimentary coccyx for- ward, and marked by a slight depression of the exterior surface known as the cloacal fossa (Fig. 4199). In front of uterus this there forms a conical outgrowth known as the genital eminence (eminentia genitalis) which increases rapidly in size and forms at its top a rounded projection (tuberculum Fig. 4198.— Egg Columns or Pflilger's Tubules, showing the Divers Phases in the Production of the Ovisacs. (Duval.) .EG, Germinal epithelium with the primordial ovisacs ; A, egg column or tubule of Pfluger in its primitive state ; B and C, tubules assuming a chaplet- like form ; JD, breaking up of the chaplet ; the ovisacs become inde- pendent ; 0, 0, 0, ova. genitale) that becomes, later, either the clitoris or the glans penis (Fig. 4199). Behind this occurs a slit-like depres- sion of the cloacal membrane, the urogenital cleft (ritna genitalis) bounded on each side by two folds, the inner genital folds (plica genitales), which finally become, in the= female, the nympha? and the frenulum of the clitoris. genital tubercle genital eminence genital fold tip of the coccyx cloacal fossa Fig. 4199.— The External Genital Organs of a Foetus of Seven Weeks. (Toldt.) The urinary and genital canals discharge into a common opening, the cloacal fossa. In the mean time the cloaca becomes divided, by means of a septum (septum urogenitale) formed by two folds that grow in from the sides, into two compartments, a ventral one, the urogenital sinus, and a dorsal one which becomes the rectum (Fig. 4200). This division affects glans clitoridis labium majus I pudendi ) genital fold sinus uro-l genitalis ] perineum Fig. 4200.— The External Genitals of a Female Foetus at the Middle of the Third Month (5.6 cm. long). (Toldt.) Complete separation of the anus from the urogenital sinus. also the cloacal membrane, the ventral portion of which now closes in the urogenital cleft, and is known as the urogenital membrane. This soon thins away aud disap- 149 Sexual Organs. Sexual Organs. REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. pears so that the cleft opens immediately into the uro- genital sinus. There now arise, at the base of the genital eminence on either side, two rounded folds, the outer genital or labio- glans clitoridis nympha vestibulum I vaginae f labium majus raphe perinei Fig. 4201.— The External Genitals of a Female Fcetus at the End of the Fifth Month (11.5 cm. long). (Toldt.) scrotal folds (tori genitales), which extend backward as far as the anus and join each other in front around the genital eminence. These become the labia majora of the female or the scrotum of the male (Fig. 4201). The Ovaries.— Etymology. — From the Neo-Latin ova- rium, a derivative from ovum, an egg. Greek, aofSpov, from whence many compounds arise, such as oophorec- tomy, ooplwralgia, oophoritis, etc. French, ovaire ; Ital- ian, ovario ; German, Eierstock. The name was first used in 1667 by the Danish anatomist, Nil Stensen, who sup- posed the ovisacs to be ova. The ancients, recognizing their analogy to the male genital glands, called them testes muliebres. History. — The Alexandrian anatomists probably knew them, and they were described by Soranus of Ephesus (a.d. 117) who considered them as useless bodies, and also by Galen, who supposed them to secrete a female semen, very fluid and "cold," which was conveyed to the uterus by the oviducts. Athenaeus (a.d" 69) denied this, as did afterward Fallopius. It was, however, generally held up to the time of De Graaf, who, in 1672, insisted that their proper use was to gen- erate ova, to nourish them, and to bring them to maturity. The ovisacs were known and mentioned under various names by Vesalius, Fallopius, Bartho- linus, and others. Jan Van Home, professor at Leyden, was the first to call them ova, and thus emphasize the egg-produc- ing function of the ovary. The veritable ovum was not discov- ered until 1827, when von Baer described it. Definition. — The organs of the female, in which are developed the ova, or essential sexual prod- ucts. They differ from ordi- nary secreting glands in that they do not form new prod- ucts, but merely develop and mature structures that already exist in them, in a rudimentary condition, at birth. Form.— The human ovary (Fig. 4202, 4) is a solid, 150 almond-shaped body, about 4 cm. long by 2 cm. wide and 1 cm. thick (1J X i X i in.) in the adult (Fig. 4203); in childhood and old age considerably less. It may vary from this typical form and be disc-like, cylindrical, tri- angular, or irregular. The right ovary is slightly larger than the left. The attached edge of the ovary is nearly straight, the free edge usually curved. Its extremities, also called poles, are distinguished as inferior, or uterine, and superior, or tubal, the latter being attached to the infundibulum of the oviduct. Color. — This is a soft, dull, reddish-gray, like that of a mucous membrane, easily distinguished from the smooth, glistening appearance of the neighboring organs due to their peritoneal covering. The peritoneum, form- ing the broad ligament and the mesovarium, abruptly ceases at the attached edge of the ovary at a crenulated line (Fig. 4203, 1, Farre's line ; Arthur Farre, physician of London, circa, 1840), and the organ presents its bare surface in the abdominal cavity, being the only one that, in the strict sense of the word, is within the peritoneal sac. The reddish tint increases during the hyperaemia preceding menstruation and decreases after the meno- pause. Consistency. — Although in youth quite dense and re- sistant to pressure, the development of the vascular tis- sue in the ovaries is such as to make them slightly spongy, and at puberty they are not as firm as the testes of the male. Their density increases after the meno- pause. Before menstruation the surface is smooth, but afterward the development and rupture of the ovisacs produce on the surface elevations and depressions that have been compared to those of a peach stone or to the convolutions of the brain (ovarium gyratum, Abel). Weight. — This naturally varies with the size of the ovary, being 50-60 cgm. at birth, 4 or 5 gm. at puberty, 6-8 gm. in the adult, and decreasing gradually to a gram or less in old age. It is thought that a rapid increase of weight occurs from the hyperaemia of the menstrual period. Attachments. — The cavity of the pelvis is transversely divided into two compartments by the broad ligament, a fold of peritoneum that encloses the uterus and the ovi- ducts. The ovaries are attached edgewise to the postero- superior surface of this fold by a short peritoneal dupli- Fig. 4202.— The Uterus and Annexa seen from Before. (On the left side the oviduct is turned down to show the ovary which is slightly raised.) 1, Body of the uterus, covered by peritoneum ; 2, its cervix, with the external orifice; 3, vagina, its anterior wall removed; 4, left ovary: 5, liga- ment of the ovary ; 6, oviduct, with 6', its infundibulum ; 7, ovarian fimbria and tubo-ovarian ligament ; 8, -hydatid of Morgagnl ; 9, round ligament ; 10, broad ligament, with a, b, c, its three 1 " ' ■" ; " """• ■ 11, posterior layer of the broad ligament; 12, ovarian vessels; 13, divisions or "'ailerons' uterine vessels. cature termed the mesovarium (Fig. 4202, c, Fig. 4203, 0), which is continued upward from the superior pole of the ovary as a triangular band, the suspensory ligament (Fig. 4204), containing the ovarian vessels and nerves, some unstriped muscular fibres, and a long fimbria from the REFERENCE HANDBOOK OF THE MEDICAL SCIENCES. Sexual Organs. Sexual Organs. extremity of 'the oviduct (Fig. 4202, 7). At the inferior pole is attached the ligament of the ovary (Fig. 4202, 5), a fibro-areolar structure containing some muscular fibres] that extends in the folds of the broad ligament to the i $ . ■n'jjf Jr fill 1I?p$ S-'—j^k. jM 0m'V' ] ';» ^fV {■■■■ , M. . ' $ ' \ *wk J^ if irV " '■J/ "^k j|||^ftJS|»a, tunica fibrosa or external layer of the ovisac ; c, in- ternal tunic hypertrophied and folded ; d, remains of the membrana granulosa, e, vessel supplying the ovisac. A. follicular I . epithelium f vascular bud • Mm theca - disappear; the connective tissue contracts to a whitish mass {cor- pus albicans), and finally to a fibrous remnant (corpus ffibro- 8um), which is at last also removed by hyaline degen- eration. Observers are not fully in accord as to the origin of the lutein cells. Sobotta, after very careful observations on the mouse, concludes that they are of epithelial origin, arising from a hypertrophy of the granulosa (Fig. 4209), and in this he is supported by Bischoff, Pfliiger, and many others. Another view, is that they are of connective - tissue ori- gin, arising from the cells of the tunica in- terna, and that the granulosa wholly dis- appears. Observations on abortive ovisacs seem to support this view, which is warmly defended by Clark, Minot, Paladino, and others. The matter cannot be definitely settled until human material, showing the earlier stages, is more fully investigated. The function of the corpus luteum has been the subject of much discussion. Born, struck with the resemblance of its structure to that of the suprarenal capsule, advanced the hypothe- sis that the organ is a ductless gland that modifies the blood so as to produce the changes in the uterus necessary for the en- capsulation and subse- quent nutrition of the ovum. He argued that the corpus luteum is much larger than would be necessary for the mere restoration of the ovarian tissue, and that the growth of the uterus during pregnancy is not due to distention by the growing ovum, but is accompanied by profound structural changes, which may be initiated without the ovum being in the uterus at all, as in the well-known case of extra-uterine pregnancy. Further, mammals that have a placenta which becomes firmly attached to the uterus have a well-developed corpus luteum, while the aplacental mammals (monotremes, marsupials) have only a rudimentary one or none at all. Frankel and Colin found that in rabbits the removal of both ovaries within six days after copulation always prevented pregnancy. According to this view, the cor- pus luteum of menstruation may have an effect upon the restoration of the uterus. Clark and others contend that the organ is required to maintain the peripheral circulation and proper surface tension in the ovary by preventing the formation of cica- tricial tissue at the point of discharge of the ovum. If each rupture of an ovisac were followed by a typical scar, the entire surface of the ovary would soon be re- duced to inactivity. Arteries. — The ovary is supplied by the ovarian artery, which arises from the abdominal aorta just below the renal arteries, and descends by a flexuous course into the pelvis through the suspensory ligament of the ovary, its long course being explained by the fact that the ovary was primitively an abdominal organ. It gives off a tubal branch that supplies the fimbriated extremity of the ovi- duct, ten to fifteen ovarian branches, and is continued to make a free, anastomotic loop with the uterine artery. During pregnancy, when it is greatly enlarged, it is an important supplementary source of supply for the rapidly growing uterus. The small ovarian branches penetrate the ovary along its attached border, the place of entrance, which also serves for veins, nerves, and lym- phatics, being called the hilum. Their course is heli- cine or corkscrew-like, not only in the broad ligament, j ovarian 1 epithelium ■-■ leucocytes C. Fig. 4209.— Formation of the Corpora Lutea according to Sobotta. Four successive stages in the mouse. A, Vascular budding of the tunica interna invading the hypertrophied follicular epithelium ; B, the vascular buds converge toward a central cavity. Between them the follicular cells, which are rapidly multiplying, are arranged in columns. Among these cells leucocytes are found. C, A more advanced stage ; the columns are now narrower and the trabecule more numerous. D, The central cavity is now occupied by a gelatinous connective tissue ; the trabecule, by anastomosing with each other, have destroyed the columnar arrange- ment of the lutein cells. but also in the substance of the organ. In the medullary- portion they form the rich anastomoses which cause this to be named the vascular zone ; and at the confines of the cortical and medullary portions they form imperfect arcades from which arterioles are given off which pene- 153 Sexual Organs. Sexual Organs. REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. trate to the ovisacs and the corpora lutea and form a capillary network about them. Veins. — These are large, sinuous, spiroid in character, and accompanied by bands of smooth, muscular fibre Vp. w. Ci. n: .. Gtm. CLW. C.tJ. c.i. Fig. 4210— Scheme Showing the Development of the Sexual Gland and Its Duets. (Mibal- kOTics.) A, Indifferent stage; B, female; C, male; Cp.w., Wolffian body with the epo- ophoron (epo) and the epididymis (epi); Cl.w., Wolffian duct; C.s., sexual radiations; Glm., Wolffian glomeruli ; C.H., body of Highmore Crete ovarii) ; E.g., germinal epithelium ; V.eff ., efferent ducts of the testis. like those of erectile tissue. In the hilum, mesovari- um, and neighboring folds of the broad ligament the veins form a vascular protuberance called by Rouget the bulb of the ovary, and believed by him to have some function in ovulation. Leaving the broad liga- ment, the veins unite to form the pampiniform plexus and finally discharge into the uterine and ovarian veins. Lymphatics.— These are very numerous. They origi- nate in the stroma and about the ovisacs, some of the smaller sacs being often nearly surrounded by a lymph sinus. Converging to eight to ten trunks, they pass out at the hilum, accompany the vessels and discharge into glands sit- uated in front of the aorta. Nerves. — These are derived from a sympathetic plexus that is given off from the renal plexus and accompanies the ovarian artery. The exact terminations are imperfectly known. They have been traced to the walls of vessels, to smooth muscular fibres, to the surface epithelium, and to the tunica interna of the Graafian follicles. Vestigial Structures. — There remain within the ovary, in the folds of the broad ligament and elsewhere, certain vestiges of the foetal condition of the organs that it is necessary to briefly mention. These are as follows: The epoophoron, parovarium, or body of Eosenmiiller (Fig. 4210, B, Fig. 4211) consists of six to twelve nearly parallel tubes containing a clear fluid, which are found within the folds of the mesosalpinx. They converge toward the hilus of the ovary, and may in young animals be traced into its substance (see Fig. 4210 B, O.8.). Toward the oviduct they end in a longi- tudinal canal, the remains of the Wolffian duct. They represent vestiges of the sexual part of the Wolffian 154 body, and are homologous with the seminiferous tu- bules and vasa efferentia of the male. The paroophoron is a similar series of tubes found in the broad ligament nearer the uterus, and representing the unused urinary part of the Wolffian body (Glm, A, Fig. 4210). They are of a yellowish color and usually disappear early. Gartner's Canal. — This is the remains of the lower part of the Wolffian duct occasionally found in the wall of the uterus and vagina. It is homologous with the vas deferens of the male. Hydatids of Morgagni. — In about twenty per cent, of subjects there is found connected with the in- fundibulum of the oviduct, usu- ally with the ovarian fimbria, a small hollow cyst known as the hydatid of Morgagni. Similar structures may be found in the folds of the broad ligament in connection with the epoophoron. Their homologies and origin are obscure. The Oviducts. — Etymology. — From the Neo-Latin oviductus, derived from the Latin ovum, an egg, and ductus, a leading, a pas- sage. Greek, oaXmyi;, from whence many compounds, such as salpingitis, salpingotomy, etc. ; French, ovi- ducte, trompe uterine; Italian, ovidutto, tromba de Fal- loppio; German, Mleiter, Muttertrompete. The name was first used by De Graaf, about 1672. The older an- atomists styled them vasa deferentia. Often called the Fallopian tubes, from Gabriello Falloppio (1523-62), pro- fessor at Ferrara, Pisa, and Padua, who compared their expanded ends to that of a brazen tuba or trumpet. This name was first given them by Riolanus about 1618. In the nomenclature of the German Anatomische Gesell- FiG. 4Z11.-View of Lateral Angle of Uterus with Broad Ligament from Behind. (Henle.) TJU uterus ; LI, broad ligament ; Od, isthmus of oviduct ; Od', ampulla of oviduct ; J, inf un- aioulum; Oa, abdominal opening of oviduct; Fo, ovarian fimbria; to, suspensory ligament; fo, epoophoron laid bare by removal of part of the posterior lamella of the broad ligament. schaf t they are known as the tuba uterinm. Some authors restrict the term oviduct to the genital passages of ani- mals possessing no uterus. There seems no good reason for this. History.— They were probably known to Herophilus REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. Sexual Orgaus. Sexual Organs. (335-280 B.C.). Eudemus (290 B.C.) described the fim- briated extremity. Rufus of Ephesus demonstrated them in the sheep about a.d. 50. They were generally supposed to convey the product of the ovary, the hypo- thetical female semen. Fallopius showed that they did not closely connect with the ovaries, and considered that "fuliginous vapors" exhaled from the uterus through them into the abdomen. Others supposed them to be spiracles through which " spirits " could pass from the mother to the foetus. Definition. — Paired tubular structures, extending from near either ovary to the uterus, by which the mature ova are conveyed from the peritoneal cavity to the latter organ. They differ from the ducts of secreting glands in being detached from the organ whose products they are intended to convey. Form. — The general shape of an oviduct (see Fig. 4191) is that of a gradually expanding, sinuous trumpet, ex- tending laterally from either angle of the uterus, of which it appears to be a continuation. This is even more stri- king in the lower animals, in whom the fusion of the Miillerian ducts is not so complete, and who consequently possess a bicornuate uterus. Divisions. — Starting from the uterine cavity we may ■distinguish (Figs. 4191 and 4202): (1) a uterine, intra- mural, or interstitial portion, passing through the walls of the uterus, in which the lumen of the duct is reduced -to very small dimensions; (2) the isthmus, a narrow, com- paratively straight portion, having no well-defined limit, but generally reckoned as about one-third the length of the duct; (3) the ampulla, an enlarged, sinuous portion which terminates by (4) the infundibulum or fimbriated extremity, a funnel-shaped expansion surrounded by a fringe-like border by which the duct opens into the peri- Fir.. 4212.— Relations of the Ovary and the Oviduct. (His.) 0, Ovary ; P, infundibulum ; T, oviduct ; L, ovarian ligament ; U, uterus. The annexa are held up by the suspensory ligament. The fundus of the uterus deviates somewhat from the median line. toneal cavity. The junction of the infundibulum with the ampulla, sometimes slightly constricted in young per- sons, is occasionally called the neek. The uterine orifice is small, inextensible, and often stopped by a plug of mucus. It is practically impossi- ble to catheterize it, and fluids injected into the cavity of the uterus do not readily pass through it. The ab- dominal orifice is larger and extensible. It is said to be closed in tubes cut from the living, but open after death. We may, with Waldeyer, consider the oviduct according to the directions which its different parts assume. A Iwrizontal portion extends from the angle of the uterus outward and a little backward to the inferior pole of the ovary, an ascending portion, nearly at right angles to the preceding, which mounts vertically along the pelvic wall and the mesovarian margin as far as the superior pole, and a short descending portion which makes an acute angle with the latter, passing downward and inward, forming the so-called tubal loop, the infundibulum em- bracing the internal face and posterior border of the ovary (Fig. 4212). These portions are, however, by no means of fixed dimensions, as they depend largely upon the position of the uterus and upon the various influences that may displace the ovary and the folds of the broad ligament. The oviduct, with its attached peritoneum, often so covers the internal face of the ovary that that organ is not perceived when the pelvic cavity is opened. Dimensions. — The following table shows the principal measurements of the oviduct: Average length 12 to 14 cm. Minimum length 6 Maximum length 20 Length of interstitial portion 1 Length of isthmus 3 Length of ampulla 8 Length of infundibulum 2 Length of ovarian fimbria 2.5 to 3 " Length of other fimbriae 1 to 1.5 " Calibre of uterine orifice 05 to .1 " Calibre of interstitial portion 05 Calibre of isthmus near uterus 3 Calibre of ampulla, maximum 8 Calibre of peritoneal oriflce 2 to .3 " Thickness of walls, average 2 to .3 " At its uterine termination the tube so gradually ex- pands into the cavity of the superior cornu that its exact point of termination is difficult to determine. Attachments. — Continuous with the angle of the uterus at its inner extremity, the oviduct lies in the superior or free edge of the broad ligament, hereafter to be described, and is attached at its lateral end by one of the fimbria, longer than the others (ovarian fimbria, fimbria ovarica, Figs. 4202 and 4203), to the suspensory ligament of the ovary. The triangular fold of the broad ligament that encloses it is known as the mesosalpinx (Fig. 4202, b). At its extremities the duct shares the movements of the organs to which it is attached, while its intermediate portion may move independently, its freedom depending upon the length of the duct and the laxity of the meso- salpinx. Interstitial Portion. — In nulliparae the oviduct is clearly seen to be a contracted continuation of the supe- rior cornu of the uterus, and the narrowest point is not at the uterine orifice, but a little beyond. In multipara;, however, the orifice is the narrowest portion. While passing through the uterine wall the duct is slightly bent with downward concavity. A layer of connective tissue separates it from the uterine substance proper. Isthmus. — This resembles the vas deferens in its cord- like, resistant character and cylindrical form. It lies in the para-uterine fossa of Waldeyer, the round ligament of the uterus being before and below, the ovarian ligament and tubo-ovarian artery behind. Ampulla. — This portion, slightly flattened from before backward, has a thinner wall and softer consistence than the isthmuss It is slightly irregular in calibre, with tlexuosities which are more marked in the young. Its loop runs in front of the ovarian vessels and its descend- ing branch is close against the external iliac vein. Infundibulum. — This funnel-like expansion (Fig. 4202, 6") is cut into twelve to fifteen laciniate, fringe-like proc- esses or fimbria, and is hence often called the fimbriated extremity. The French, carrying out the similarity of the duct to a trumpet, call it the pavilion, a name also applied to the flaring mouth or bell of a trumpet. The ancients compared its gnawed appearance to the pre- morse root of the Scabiosa succisa, popularly known as the "devil's bite," the legend being that the arch enemy, angered at the good done by the medicinal virtues of the root, attempted to destroy it by biting it off, but only succeeded in leaving a ragged edge showing the marks of his attack. It is from the resemblance of the infun- dibulum to this root, and not from any evil influence it was supposed to exert, that it was called the morsus dia- boli. It has also been compared to the corolla of a flower with a double row of petals (Henle), to a crinoid or sea- lily (Nagle), and to a medusa head. The single fimbriae are lanceolate, ovate, or filiform, not infrequently with irregularly notched edges, so that there may arise fimbriae of the second or third order. Sometimes they may be fenestrated or form a lattice- work. One of them, larger than the others, has already been referred to as the ovarian fimbria (Fig. 4202, 7). Attached to a groove in the suspensorj- liagment, it does not usually quite reach the ovary, and from its tennina- 155 Sexual Organs. Sexual Organs. REFERENCE HANDBOOK OP THE MEDICAL SCIENCES. tion there may extend, along the suspensory ligament, supplementary fringes (tubo-ovarian fimbriae). The pri- mary fimbriae are usually plicated, the folds correspond- ing to those of the mucous membrane of the interior of I longitudinal mus- I oular fibres subserous tissue Via. 4213.— Cross-Section of the Oviduct near the Uterine Orifice. (Orthmann.) the tube. In consequence of this arrangement, the ab- dominal orifice of the tube is not usually visible, at least in nulliparae. It can, however, always be displayed by parting the plications, and is large enough to admit a small probe. It is by this orifice that the ova leave the abdominal cavity, and many attempts have been made to clearly explain how they come to enter it. It was formerly supposed that at the time of ovulation the inf undibulum suffered a species of erection by vascular congestion, and that then it clasped itself firmly around the ovary and prevented the escape of the ovum into the peri- toneal cavity. Injection of the vessels in the ca- daver does not confirm this, and, as Henle says, it is difficult to see how the infundibulum can select the exact place upon the ovarian surface where a fol- licle is about to rupture, or how it can be depended upon to execute such a