CORNELL UNIVERSITY THE Siawtr Bptprtnary ICtbrarg FOUNDED BY ROSWELL P. FLOWER for the use of the N. Y. State Veterinary College 1897 5541 R 121.02*1884 """*"""' "*""y The original of tiiis book is in tine Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924000286280 DICTIOMRY OF MEDICIM INCLUDIKG GENERAL PATHOLOaY, GENERAL THERAPEUTICS, HYGIENE, AND THE DISEASES PECULIAR TO WOMEN AND CHILDREN BY VARIOUS WRITERS EDITED BY EIOHAKD QUAIN, M.D., F.E.S. FBLLOTT iND LATB SENIOE CENSOB OF THE BOYAL COLLEGE OF PHYSIOlAITa; MEMBEE OF THE SENATE OF THB TTNIVEEBITT OF XONDON; MEMBER OF THE GENEEAL COUNCIL OF MEDICAL EDTTOATION AND EEGISTBATION ; CONSTTLTIITG PHYSICIAN TO THE HOSPITAL FOE CON- SUMPTION AND DISEASES OF THE CHEST AT BEOMFTON, ETC, EIGHTH EDITION. NEW YORK D. APPLETON AND COMPANY 1, 3 AND 5 BOND BTEEET 1884 PREFACE. The vast number of facts and observations, by which the recent progress of scientific and practical medicine has been marked, is dif- fusely recorded in the Transactions of learned societies, in journals, in monographs, and in systematic treatises. With progress so rapid, and information so diffused, it is extremely difficult alike for the practitioner, the teacher, and the student to keep pace. It was the perception of this difficulty which induced the Editoi, when invited to undertake the production of a new Medical Dictionary, to engage in a task which, he was fully conscious, must be one of great labour and . of great responsibility. He felt, however, that he would be rendering useful service to his profession if he could bring together the latest and most complete information in a form which would allow of ready and easy reference. Accordingly, he invited the co-operation of certain of his colleagues and professional friends, both in this country and abroad ; and evidence of the readiness with which this invitation has been accepted, is afforded by the list of contributors. Each contributor volunteered or was invited to write on a subject with which he was specially familiar. The present, work, which is the result of these combined efforts, may therefore be regarded not only as a dictionary, but also as a treatise on systematic medicine, in which the articles on the more important subjects constitute monographs in themselves, whilst definitions and descriptions of matters having less claim to extended notice are given as fully as is required. Thus an endeavour has been made to supply, in a clear, condensed, and readily accessible form, all the information that is at present available for the use of the practitioner of medicine. As indicated on the title-page, the work is primarily a dictionary of Medicine, in which the several diseases are fully discussed in alphabetical order. The description of each includes an account of its n PEEFACE. Eetiology and anatomical characters ; its symptoms, course, duration, and terminations; its diagnosis, prognosis, and, lastly, its treatment. General Pathology comprehends articles on the origin, characters, and nature of disease, and the many considerations which these topics suggest. General Therapeutics will he found to include articles on the several classes of remedies — medicinal or otherwise — which are avail- able for the purpose of treatment ; on the modes of action of such remedies ; and on the methods of their use. The articles devoted to the subject of Hygiene will be found to treat of the causes of disease, of its prevention, of the agencies and laws affecting public health, of the means of preserving the health of the individual, of the construction and management of hospitals, and of the nursing the sick. Lastly, the diseases peculiar to Women and Children are discussed under their respective headings, both in aggregate and in detail. It may be well to explain that, although it has been found neces- sary to include some notice of diseases which fall more generally under the care of the surgeon, the work does not pretend to be a dictionary of Surgery; and also that, although certain drugs are enumerated in discussing subjects of general therapeutics, and of poisons and their actions, there has been no intention to invade the domain of Materia Msdica. It is right to observe that all the articles have been edited and revised with great care, so as to ensure a completeness and unity in the work, which it is not always possible to obtain in books composed by a number of writers. The Editor desires also to state that, although the work has occu- pied several years in preparation, arrangements were made with the printers which have enabled him to revise every article which required revision, up to the time of going to press. Further, by the addition of an Appendix it has been possible to incorporate the latest contributions to medical knowledge. Having thus set forth the aims and objects of his undertaking, and how far they have been carried out, the Editor has the great satis- faction of offering his thanks to his friends and colleagues, for the valuable assistance which he has received from them. He is fully conscious of the trouble which must often have been necessary in order PREFACE. Tii to condense extended knowledge of a familiar subject within the limited space which the nature of this woi'k could afford. The Editor has further the pleasing duty of offering his special thanks to De. Feedeeick T. Eobeets and to De. J. Mitchell Beuce, who from the first have been his Assistant-editors and fellow-labourers. Without the help which they have, afforded him, it would have been impossible for him to have fulfilled the duties which he undertook. He is well aware of the time and labour which their assistance has involved ; and he appreciates most fully the marked ability by which i t has been characterised. The Editor cannot conclude without a reference to some of those who were his friends and colleagues when this work was commenced, but who have since been taken away by death. He would specially mention the names of Edmund Parkes, Chaeles Muechison, GtEOEGE Callendee, Thomas Bevill Peacock, John Eose Cormack, Lockhart Clarke, Ttt,BURY Fox, Thomas Hayden, Harry Leach, Alexander Silver. The loss of these eminent men, many of them dear and valued friends, and all of them taken too soon from their unfinished labours, is to him a source of personal sorrow. The articles written by them for these pages were in most instances their last contributions to medical literature, and will be valued accordingly. LoirsOK ; September 1882. LIST OF ILLUSTEATIONS. IIG. PAQ" 1. CKdium aCbieana 71 2. Bilharzia Immatobia, male and female . 107 3. Silharziah tematobia, ovum of, with contained embryo and free sarcode- gianules 107 4. Cardiogram 210 5. Benal casts— blood 213 6. „ hyaline . . . .213 7. „ epithelial . . . .213 8. „ fatty 213 9. ., granular .... 213 10. „ enclosing crystals, and a smaller cast ; also cast of seminal tubule with spermatozoa . . . 213 11. Filaria sangmnis-hominis . . . . 252 12. Side view of the left hemisphere of the monkey, illustrating localisation of the cerebral centres .... 297 13. Side view of the left hemisphere of man, illustrating localisation of the cerebral centres 297 14. Cysticercus {telse) cellulosse, removed from the human eye 323 15. C^sjicerci in a portion of measled pork 323 16. Distoma conjunctum 401 17. Dracunculus mediiiensis .... 403 1 8. Filaria sanguinis-kominU, anterior end of the mature 512 19. Filaj-ia sangmnis-hominis, a portion of the mature^ showing uterine tubules, &c. . 512 20. Filaria soTiguinis-hominis, ova and em- bryos of 513 21. Fungoid filaments and capsules from fungus disease of India . . . 522 22. Fatty degeneration of the heart . . 594 23. Fatty growth in the substance of the heart 697 24. Hydatids of four weeks' growth, showing ectocyst and endocyst .... 654 25. Group of Echinococoi, with their hook- crowns inverted 634 26 The so-called ' Echinocoocus head,' show- ing hooks, suckers, cilia, and corpuscles 654 FIQ PAQH 27. Micrococci, different forms of . , 974 28. Red blood-corpuscles — ^human . to fact 982 29. Scaly epithelial cells . »> 982 30. Leucocytes ; pus, mucous, or white blood-corpuscles .... ») 982 31. Ciliated epithelial cells . » 982 32. Cotton fibres, showing character- istic twist »» 982 33. Milk, showing colostrum corpuscles and oil-globules .... »j 982 34. Particles of vomited matter . )» 982 35. Epithelium from urinary tracts j» 982 36. Spermatozoa — human » 982 37. Fragments of hair .... )» 982 38. Sarcina ventriculi .... »» 982 39. Hooklets of echinocoocus it 982 40. From phthisical sputum, showing elastic fibres of lung-tissue and leucocytes » 982 41. Heemin crystals from old blood-clot » 982 42. Cubes of chloride of sodium . „ 982 43. Leucin ij 982 44. TjTosin ... »j 982 45. Uric acid, various forms . n 982 46. Cholesterin plates .... » 982 47. Cystin » 982 48. Oxalate of lime : dumb-bells and ootahedra „ 982 49. Triple phosphate of amnlonia and magnesia )J 981 60. Torula cerevisise : yeast fungus „ 982 51. Sputum of early pneumonia, showing red blood-corpuscles and leucocytes .... », 982 52. Shreds of elastic tissue in sputum of phthisis »» 982 63. Oidium albicans ; thrush . » 982 54. PmicilUum glaucum »» 982 65. Pulse-trace— typical . 1295 56. „ of high tension . 1295 LIST OF ILLUSTEATIONS. FIO. pjKjK 57. Pulse-trace — of low tension . . .1295 58. „ hard, frequent, sudden, and small pulse . . . 1297 59. „ hard, slow, gradual, and large pulse . . . 1297 60. „ hard, large, gradual pulse . 1298 61. „ hard, sudden, large, and vibratory pulse . . 1298 62. „ soft, frequent pulse . . 1298 63. „ soft, frequent, and large pulse .... 129S 54. „ soft, small, frequent, and sudden pulse . . . 1298 65. „ soft,frequent,andsmall pulse 1298 66. The spleen in anthrax .... 1303 67. The spleen in anthrax under a high power 1303 68. Forms of Baeillus anthraeis . . , 1303 69. From a cultivation of Bacillus anthraeis, after forty-eight hours . . . 1304 70. Bacilli from the fluid exuded from the lung in a case of internal anthrax .1305 71. Ascaris lumbricoides ; male, with exserted spicules 1379 72. Ascaris mystax, male and female . . 1380 73. Sclerostoma duodenale, male and female . 1398 74. Sphygmographic tracing, showing ob- structed peripheral circulation . . 1452 75. Sphj'gmographic tracing, showing easy and quick capillary circulation . . 1452 76. Sphygmographic tracing, showing hyper- dichrotism 1452 77. Sphygmographic tracing, showing con- traction of muscular coat of artery . 1452 78. Sphygmographic tracing, showing ri- gidity of arterial walls ... 1462 79. Sphj'gmographic tracing of right radial artery in aneurism of the aorta . . 1463 80. Sphygmographic tracing of left radial artery ia aneurism of the aorta . . 1463 81. Sphygmographic tracing in aortic regur- gitation 1453 82. Sphygmographic tracing in aortic sten- osis • 1453 83. Sphygmographic tracing in mitral regur- gitation 1454 84. Sphygmographic tracing in mitral sten- osis 1454 85. Transverse secticins of the normal spinal cord 1456 B6. Transverse sections of the spinal cord, showing areas of descending degene- ration 1461 87. Transverse sections of the spinal cord, showing areas of ascending degene- ration 1461 88. Spirillum Obermeiui, amrngst red blood- cprpusoles .,,... 1508 89. Tsenia echinococcus 15 85 90. T^raw me(fiOcane//ata, unarmed head of , 1585 91 Tamia solium, armed head of , . 1685 FIG. F^QB 92. Tienia mediocanellala, proglottis of . . 1585 93. Tania solium, proglottis of . . 1585 94. Teenia mediocanellata, head and several segments of 1586 95. Oxyuris vermicularis, female . . 1624 ^Q. Oxyuris vei'micularis, eggs of. . 1624 97. Trichina spiralis, male and female . 1657 98. Trichina, a single capsuled, in a portion r of human muscle . . . . 1657 99. Trichocephalus, male and female . 1659 100. Tubercle in a lymphatic gland . 1663 101. Fibroma (neuroma) to face 1672 102. Polypus of nose . „ 1672 103. Myxoma „ 1672 104. Ossifying chondroma . „ 1672 105. Enchondroma (of jaw) . „ 1672 106. Enchondroma (of orbit) . „ 1672 107. Myeloid of jaw . „ 1672 108. Large round-celled sarcoma . „ 1672 109. Small round-celled sarcoma . „ 1672 110. Oval-celled sarcoma „ 1672 111. Lymphoma .... „ 1672 112. Small spindle-celled sarcoma „ 1672 113. Alveolar sarcoma . „ 1672 114. Mixed sarcoma „ 1672 116. Melanotic sarcoma „ 1672 116. Large spindle-celled sarcoma „ 1672 117. Papilloma of soft palate „ 204 118. Epithelioma of lip 204 119. Edge of rodent ulcer . 204 120. Simple polypus of rectum . „ 204 121. Columnar epithelioma of intes- tine » 204 122. Colloid of breast .... „ 204 123. Cancer of liver (sciiTho-encepha- loid 204 124. Enoephaloid cancer „ 204 125. Scirrhus infiltrating fat „ 204 126. Cicatrizing cancer 204 127. Scirrhus of mamma „ 204 128. Adenoid of upper jaw (benign) . „ 204 129. Ulcerated adenoid of parotid (malignant) .... « 204 1 30. Adenoid of breast (common type) . « 204 131. Adenoid of breast (epithelial ele- ment in excess) . . . ,, 204 132. Adenoid of breast (adeno-sar- coma) .... „ 204 133. Urinary flocculi . 1710 134. Vaginal speculum— Cusco'sbi-vol re . 1777 136. „ Fergusson's . 1777 136. „ the duck-bill . 1777 137. Uterine sound . 1778 138. Uterine probes . . . 1781 ■LIST OF CONTEIBUTOE8. ADAMS, WILLIAM, Surgeon to tUe Great Northern Hospital. AITKEN, WILLIAM, M.D., F.E.S., Professor of Pathology in the Aimy Medical School, Netley. ALLBUTT, T. CLIPFOEI), M.A., M.D., F.R.S., Senior Physician to the Leeds GenenU Infirmary, and Lecturer on Practice of Physic, Leeds School of Medicine. ALLCHIN, W. H., M.B., F.E.S.E., Physician to, and Lecturer on Physiology and Pathology at, the Wostminster Hospital; Physician to the Victoria Hospital for Children. ANDEEW, JAMES, M.D., Physician to, and Joint Lecturer on Physic at, St. Bartholomew's Hospital; Consulting Physician to the City of Loudon Hospital for Diseases of the Chest. BALFOUR, GEOEGE W., U.D., F.E.S.E., Physician to the Eoyal Infirmary, and Con- sulting Physician to tho Eoyal Hospital for Children, Edinburgh. BANHAM, G. A., late Veterinary Assistant at the Brown Institut;ion. BAENES, EOBEET, M.D., Obstetric Physician to, and Lecturer on Midwifery and Diseases of Women at, St. George's Hospital; Consulting Physician to the Eoyal Maternity Charity. BASTIAN, H. CHAELTON, M.A., M.D., F.E.S., Physician to, and Professor of Clinical Medicine at. University College Hospital ; Professor of Pathological Anatomy, University College ; and Physician to the National Hospital for the Paralysed and Epileptic. BAUMLEE, C. G. H., M.D., Professor of Clinical Medicine, and Director of the Medical Clinie, University of Freiburg in Baden. BECK, MAECUS, M.B., M.S., Assistant Surgeon to, and Assistant Professor of Clinical Surgery at, Ufiiversity College Hospital. BEDDOE, JOHN, B. A., M. D., F. R. S., l*te Physician to the Bristol Eoyal Infirmary. BELLAMY, EDWAED, Surgeon to, and Lecturer on Anatomy at, the Charing Cross Hospital. BENNET, J. HENRY, M.D , late Physician-Accoucheur, Royal Free Hospital. BENNETT, SIR J. RISDON, M.D., LL.D., F.R.S., late President of the Royal College of Physicians ; Consulting Physician to St. Thomas's Hospital, and to the City of London Hospital for Diseases of the Chest. BEATEEIDGE, EOBEET, M.B., Physician to, and Lecturer on Clinical Medioiuf la, tlic Aberdeen Eoyal Infirmary. BINZ, OARL. M.D., Professor of Pharmacology in the University of iktun. *" LIST OF CONTRIBUTORS. BIRKETT, JOHN, Consulting Surgeon to Guy's Hospital. BISHOP, JOHN, M.D., CM., Assistant Surgeon to the Royal Infirmary, Edinburgh. BLANBFOKD, G. R, M.D., Lecturer on Psychological Medicine at St. George's Hospital. BOWLES, R. L., M.D., Physician to St. Andrew's Convalescent Hospital, Folkestone. BRISTOWE, J. SYER, M.D., F.R.S., Physician to, and Joint Lecturer on Medicine at, St Thomas's Hospital. BROADBENT, W. H., M.D., Physician to, and Lecturer on Medicine at, St. Mary's Hos- pital ; Consulting Physician to the London Fever Hospital. BROWN-SEQUARD, C. E., M.D., LL.D., F.R.S., Professor of Medicine, Ooll4ge de France. BRUCE, J. MITCHELL, M.A., M.D., Physician to, and Lecturer on Materia Medica and Therapeutics at, the Charing Cross Hospital ; Assistant Physician to the Hospital for Consumption and Diseases of the Chest, Brompton. BRUCE, WILLIAM, M.A., M.D., Physician to the Ross Memorial Hospital, Dingwall. BRUNTON, T. LAUDER, M.D., D.Sc, F.R.S., Assistant Physician to, and Lecturer on Materia Medica and Therapeutics at, St. Bartholomew's Hospital. BUCHANAN, GEORGE, B.A., M.D., F.R.S., Medical Officer, H.M. Local Government Board ; Consulting Physician to the London Fever Hospital. BUTLIN, H. T., Assistant Surgeon to, and Demonstrator of Surgerv at. St. Bartholomew's Hospital ; Surgeon to the Metropolitan Free Hospital. BUZZARD, THOMAS, M.D., Physician to the National Hospital for the Paralysed and Epileptic. CADGE, WILLIAM, Surgeon to the Norfolk and Norwich Hospital. CALLENDER, The late G. W., F.R.S., Surgeon to, and Lecturer on Surgery at, St. Bar- tholomew's Hospital. CANTLIE, JAMES, M.A., M.B., CM., Senior Assistant Surgeon to, and Demonstrator of Anatomy at, the Charing Cross Hospital, CARPENTER, W. B., C.B., M.D., LL.D., F.R.S. CARTER, R. BRUDENELL, Ophthalmic Surgeon to, and Lecturer on Ophthalmic Surgery at, St. George's Hospital. CAYLEY, WILLIAM, M.D., Physician to, and Lecturer on Medicine at, the Middlesex Hospital ; Physician to the London Fever Hospital. CLARKE, The late J. LOCKHART, M.D., F.R.S., Physician to the Hospital for Diseases of the Nervous System. CLARKE, W. FAIRLIE, M.A., M.D., late Assistant Surgeon to the Charing Cross Hospital. CLOVER, The late J. T., Lecturer on Anaesthetics at University College Hospital. COBBOLD, CHARLES S. W., M.B., Senior Assistant Medical Officer, Colney Hatch Asylum. COBBOLD, T. SPENCER, M.D., F.R.S., Professor of Botany and Helminthology at the Royal Veterinary College. COLLIE, ALEXANDER, M.D., Medical Officer, Fever Hospital, Homerton, LIST OF CONTRIBUTORS. iiii COOPER, ARTHUR, M.R.C.S., late House Surgeon to the Male Look Hospital. COEMACK, The late SIR JOHN ROSE, K.B., M.D., F.R.S.E., Physician to the Hertford British Hospital, Paris. CDNTSINGHAM, D. DOUGLAS, M.D., Surgeon-Major H.M. Bengal Army. CURLING, T. B., F.R.S., Consulting Surgeon to the London Hospital. CUENOW, JOHN, M.D., Assistant Physician to King's College Hospital; Professor of Anatomy at King's College ; Senior Visiting Physician to the Seamen's Hospital. DALBY, W. B., B.A., M.B., Aural Surgeon to, and Lecturer on Aural Surgery at, St. George's Hospital. DAVIDSON, ALEXANDER, M.A., M.D., Physician to the Royal Infirmary, Liverpool, and Lecturer on Pathology at the Liverpool Medical School. DE ZOUCHE, ISAIAH, M.D., Honorary Physician to the Dunedin Hospital, New Zealand. DOWN, J. LANGDON, M.D., Physician to, and Lecturer on Clinical Medicine at, the London Hospital. DUNCAN, J. MATTHEWS, M.A., M.D., LL.D., F.E.S.E., Physician-Accoucheur to, and Lecturer on Midwifery at, St. Bartholomew's Hospital. DURHAM, ARTHUR E., Surgeon to, and Lecturer on Surgery at, Guy's nospital. ECHEVERRIA, M. G., M.D., late Physician-in- Chief to the Hospital for Epileptics and Paralytics, and to the City Asylum for the Insane, New York. EWAET, JOSEPH, M.D., Retired Deputy Surgeon-General, H.M. Bengal Army; late Professor of Medicine, Principal, and Senior Physician, Calcutta Medical College. EWAR'T, 'WILLIAM, B.A., M.D., Assistant Physician to St. George's Hospital ; late Assistant Physician and Pathologist to the Hospital for Consumption and Diseases of the Chest, Brompton. FARQUHAESON, ROBERT, M.D., M.P., late Physician to the^Belgrave Hospital for Children, and late Assistant Physician to, and Lecturer on Materia Medica at, St. Mary's Hospital. FAYEER, SIE JOSEPH, K.C.SJ., M.D., LL.D., F.E.S., Honorary Physician to H.M. the Queen, and to H.R.H. the Prince of Wales ; President of the' Medical Board, India Office ; Consulting Physician to the Charing Cross Hospital. FENWICK, SAMUEL, M.D., Physician to, and late Lecturer on Medicine at, the London Hospital ; Assistant Physician to the City of London Hospital for Diseases of the Chest. FERRIER, DAVID, M.A., M.D., LL.D., F.R.S., Assistant Physician to King's CoUege Hos- pital; Professor of Forensic Medicine at King's College; Physician to the National Hospital for the Paralysed and Epileptic. FINNEY, J. M., B.A., M.D., Physician to the City of Dublin Hospital; King's Professor of the Practice of Medicine at the School of Physic in Ireland, and Professor of Clinical Medicine in Sir Patrick Dun's Hospital. FOSTER, BALTHAZAB W., M.D., Physician to the General Hospital, and Professor of the Principles and Practice of Physic at Queen's College, Birmingham. FOX, E. LONG, M.D., Consulting Physician to the Bristol Eoyal Infirmary, and late Lecturer on the Principles and Practice of Medicine at the Bristol School of Medicine. FOX, T. COLCOTT, B.A., M.B., Physician to the St. George's and St. James's Dispensary ; Assistant Physician to the Victoria Hospital for Children. nv LIST OF CONTErBUTOES. FOX, The late TILBUEY, M.D., Physician to the Skin Department, University College Hospital. ©ALTON, CAPTAIN DOUGLAS, E.E. (retired), O.B., D.C.L., F.E.S. GASCOYEN, The late GEOEGE G., Snrgeon to the Lock Hospital ; and Assistant Surgoou to, and Lecturer on Surgery at, St. Mary's Hospital. GEE, SAMUEL, M.D., Physician to St. BartholomeVs Hospital, and to the Hospital fot Sick Children ; Joint-Lecturer on Practice of Physic at St. Bartholomew's Hospital. GODLEE, EICKMAN J.,'B.A., M.B., M.S., Assistant Surgeon to University College Hos- pital ; Demonstrator of Anatomy at University College ; Assistant Surgeon to the North- East Hospital for Children. GODSON, CLEMENT, M.Di, Consulting Physician to the City of London Lying-in Hospital ; Assistant Physician-Accoucheur to St. Bartholomew's Hospital. GOWEES, W. E., M.D., Assistant Physician to, and A.ssi3tant Professor of Clinical Medicine at, University College Hospital ; Physician to the National Hospital for the Paralysed and Epileptic. GEEEN, T. HENEY, M.D., Physician to, and Lecturer on Pathology at, the Charing Cross Hospital ; Assistant Physician to the Hospital for Consumption and Diseases of the Chest, Brompton. GEEENFIELD, W. S., M.D., Professor of General Pathology and Clinical Medicine in the University of Edinburgh. GEIMSHAW, T. W., M.A., M.D., Eegistrar-General for Ireland ; Consulting Physician to the Fover Hospital, and to Steeven's Hospital, Dublin. HAWAED. J. WAEEINGTON, Surgeon to St. George's Hospital ; late Assistant Surgeon to the Hospital for Sick Children. HAYDEN, The late THOMAS, Physician to the Mater Misericordije Hospital, Dublin; Professor of Anatomy and Physiology, Catholic University, Dublin, fTEEMAN, G. ERNEST, M.B., Assistant Obstetric Physician to the London Hospital; Physician to the Eoyal Maternity Charity. HICKS, J. BEAXTON, M.D., F.E.S., Physician- Accoucheur to, and Lecturer on Midwifery and Diseases of Women and Children at, Guy's Hospital. HILL, BEEKELEY, M.B:, Surgeon to, and Professor of Clinical Surgery at, Universitj- College Hospital ; Teacher of Practical Surgery at University College ; Surgeon to the Lock Hospital. HOLMES, TIMOTHY, M.A., Surgeon to, and Lecturer on Surgery at, St. George's Hospital. HOESLEY, V. A. H., B.S., M.B., Assistant to the Professor of Pathological Anatomy, University College ; Surgical Eegistrar, University College Hospital. HOWAED, BENJAMIN, M.D., lato Professor of Medicine, and Lecturer on Medicine, in the University of New York. BUTCHINSON, JONATHAN, F.E.S., Senior Surgeon to the London Hospital, and to the Hospital for Diseeises of the Skin ; Consulting Surgeon to the Eoyal London Ophthalmic Hospital. LIST OF CONTEIBUTOES. iv IRVINE, The late J. PEARSON, B.A., B.Sc, M.D., Assistant Physician to, and Lecturer on Forensic Medicine at, the Charing Cross Hospital ; Physician to the Victoria Hospital for Children. JENNER, SIR WILLIAM, Bart., K.C.B., M.D., D.C.L., LL.D., F.R.S., Physician-in-Ordinary to H.M. the Queen, and to H.R.H. the Prince of Wales ; jpresident of the Royal College of Physicians ; Consulting Physician to University College Hospital. JONES, JOSEPH, M.D., President Board of Health, State of Louisiana, New Orleans. LATHAM, P. W., A.M., M.D., Physician to Addenbrooke's Hospital ; Downing Professor of Medicine in the University of Cambridge. LEACH, The late HARRY, Medical Officer of Health for the Port of London, and Phy- sician to the Seamen's Hospital, Grreenwich. LEGO, J., WICKHAM, M.D., Assistant Physician to, and Loetnrer on Pathological Anatomv at, St. Bartholomew's Hospital. LEWIS, TIMOTHY, M.D., Surgeon-Major, H.M. Army. LITTLE, JAMES, M.D., Physician to the Adelaide Hospital, Dublin ; Professor of Practice of Physic in the Royal College of Surgeons in Ireland ; Consulting Physician to the Rotunda Lying-in Hospital. LIVEING, ROBERT, M.A., M.D., Physician for Diseases of the Skin to, and Lecturer on Diseases of the Skin at, the Middlesex Hospital. McCarthy, JEREMIAH, M.A., M.B., Surgeon to, and Lecturer on Physiology at, the London Hospital. MAC CORMAC, SIR WILLIAM, M.A., M.Oh., Surgeon to, and Lecturer on Surgery at, St. Thomas's Hospital. McKENDRICK, J. GRAY, M.D., F.R.S.E., Professor of the Institutes of Medicine in the University of Glasgow. MACKENZIE, STEPHEN, M.D., Physician to, and Lecturer on the Principles and Practice of Medicine at, the London Hospital. MACLEAN, W. C, C.B., M.D., Inspector-General of Hospitals; Professor of Military Medicine in the Army Medical School, Netley. UACNAMABA, CHARLES, Surgeon to the Westminster Hospital, and to the Westminster Ophthalmic Hospital; Joint-Lecturer on Surgery at the Westminster Hospital. MACPHERSON, JOHN, M.A., M.D., Inspector-General of Hospitals, H.M. Bengal Army (retired) ; Physician to the Scottish Hospital. MADDEN, T. MORE, Obstetric Physician to the Mater Misericordiae Hospital, Dublin. MANSON, PATRICK, M.D., Amoy. MEREDITH, W. A,, M.B., CM., Surgeon to the Samaritan Free Hospital for Women and Children. MEEYON, The late EDWARD, M.D., Physician to the Hospital for Epilepsy and Paralysis. MUIRHEAD, CLAUD, MJ)., Physician to, and Lecturer on Clinical Medicine at, the Eoyal Infirmary, Edinburgh. MURCHISON, The late CHARLES, M.D., LL.D., F.R.S., Physician to, and Special Pro- fessor of Clinical Medicine at, St. Thomas's Hospital ; Consulting Physician to the London Fever Hospital. ^ itvi LIST OP CONTillBUTORS. MYEBS, A. B. E., Surgeon, Coldstream Guards. NETTLESHIP, EDWARD, Ophthalmic Surgeon to St. Thomas's Hospital, and to tUe Hospital for Sick Children ; Lecturer on Ophthalmic Surgery as St. Thomas's Hospital. NIGHTINGALE, FLORENCE. OLIVER, GEORGE, M.D., Harrogate. OIID, W. M., M.D., Physician to, and Lecturer on Medicine at, St. Thomas's Hospital. PAGET, SIR JAMES, Bare, D.C.L., LL.D., F.R.S., Sergeant-Surgeon to H.M. the Queen, Surgeon to H.R.H. the Prince of Wales; Consulting Surgeon to St. Bartholomew's Hospital. PARKES, The late EDMUND A., M.D., F.R.S., Professor of Hygiene in the Army Medical School, Netley. PAVY, F. W., M.D., F.R.S., Physician to, and Lecturer on Medicine at, Guy's Hospital. PAYNE, J. FRANK, B.A., B.Sc, M.D., Senior Assistant Physician to, and Lecturer on General Pathology at, St. Thomas's Hospital. PEACOCK, The late T. BEVILL, M.D., Honorary Consulting Physician to St. Thomas's Hospital ; and Consulting Physician to the City of London Hospital for Diseases of the Chest. PLAYFAIR, W. S., M.D., Physician-Accoucheur to HI. and R.H. the Duchess of Edinburgh ; Physician for Diseases of Women and Children to King's College Hospital, and Con- sulting Physician to the General Lying-in Hospital; Professor of Obstetric Medicine at King's College. POOEE, G. VIVIAN, M.D., Assistant Physician to University College Hospital ; Professor of Medical Jurisprudence, Unirersity College. POWELL, R. DOUGLAS, M.D., Physician to the Middlesex Hospital, and to the Hospital for Consumption and Diseases of the Chest, Brompton. QUAIN, RICHARD, M.D., F.R.S., Consulting Physician to the Hospital for Consumption and Diseases of the Chest, Brompton. RADCLIFFE, J. l^ITTEN, Assistant Medical Officer, Local Government Board. REDWOOD, THEOPHILUS, Ph.D., Professor of Chemistry and Pharmacy, Pharmaceutical Society of Great Britain. ROBERTS, FREDERICK T., M.D., B.Sc, Physician to, and Professor of Clinical Medi- cine at. University College Hospital; Professor of Materia Medica at University College; Physician to the Hospital for Consumption and Diseases of the Chest, Brompton. ROBERTS, WILLIAM, B.A., M.D., F.R.S., Physician to the Manchester Royal Infirmary; Professor of Clinical Medicine, Owens College School of Medicine. ROSE, WILLIAM, B.S., M.B., Assistant Surgeon to King's College Hospital ; Surgeon to the Royal Free Hospital. ROY, C. S., M.D., Professor Superintendent of the Brown Institution, London. RUSSELL, JAMES A., M.A., M.B., C.M., Inspector of Anatomy for Scotland; Lecturer on Sanitation, Watt's Institution, Edinburgh. SALTER, S. J., M.B., F.R.S., F.L.S., Late Dental Surgeon to Guy's Hospital. 6ANGSTER, ALFRED, B.A., M.B., Physician for Diseases of the Skin to, and Lecturer on Skin Diseases atj the Charing Cross Hospital. LIST OF CONTBIBUTOES. xvii SAITNDBY, E., M.D., Assistant Physician to tlie General Hospital, BirminghAm. SEATON, The late EDWARD C, M.D., Medical Officer, Local Govemment Board. 8HAPTKR, THOMAS, M.D., LL.D., Consulting Physician to the Devon and Exetei Hospital. SIBBALD, JOHN, M.D., F.E.S.E., Commissioner in Lunacy for Scotland. aiLVEIl, The late ALEXANDER, M.A., M.D., Physician to, and Lecturer on Physiology at, the Charins; Gross Hospital. SIMOK, JOHN, C.B., D.C.L., LL.D., F.R.S., Consulting Surgeon to St. Thomas's Hospital ; late Medical Officer to Her Majesty's Privy Council, and to the Local Government Board. SIMPSON, ALEXANDER E., M.D., Physician to the University Clinical Ward for Diseases of Women, Royal Infirmary, Edinburgh ; Professor of Midwifery and Diseases of Women and Children in the University of Edinburgh. i SMITH, EUSTACE, M.D., Physician to H.M. the King of the Belgians ; Physician to the City of London Hospital for Diseases of the Chest, and to the East London Hospital for Children. SMITH, W. JOHNSON, Surgeon to the Seamen's Hospital, Greenwich. SOUTHEY, EGBERT, M.D., Physician to, and Lecturer on Forensic Medicine and Hygiene at, St. Bartholomew's Hospital. SPARKS, The late EDWARD L, M.A., M.B., Physician for Diseases of the Skin to the Charing Cross Hospital, and Physician to the Royal Infirmary for Women and Children. SQUIRE, WILLIAM, M.D., Physician to the North London Hospital for Diseases of the Chest, and to St. George's Dispensary. STEVENSON, THOMAS, M.D., Lecturer on Chemistry and Medical Jurisprudence at Guy's Hospital ; Analyst to St. Pancras, &c. STEWART, T. GEAINGEE, M.D., F.R.S.E., Ordinary Physician to H.M. the Queen in Scotland ; Professor of Practice of Physic in the University of Edinburgh. STREATFEILD, J. F., Surgeon to the Royal London Ophthalmic Hospital; Professor of Clinical Ophthalmic Surgery at, and Ophthalmic Surgeon to. University College Hospital. THIN, GEORGE, M.D., London. THOMPSON, E. SYMES, M.D., Physician to the Hospital for Consumption and Diseases of the Chest, Brompton. THOMPSON, SIR HENRY, Surgeon Extraordinary to H.M. the King of the Belgians ; Consulting Surgeon to University College Hospital; Emeritus Professor of Clinical Surgery at University College. THORNTON, W. PUGIN, Surgeon to the St. Marylebone General Dispensary. THOROWGOOD, J. C, M.D., Physician to the City of London Hospital for Diseases of the Chest, and to the West London Hospital ; Lecturer on Materia Medioa at the Middlesex Hospital. TUKE, J. BATTY, M.D., F.R.S.E., formerly Lecturer on Mental Diseases at the Royal College of Surgeons, Edinbiirgh. WALKER, T. J., MX)., Surgeon to the Peterborough Infirmary and Dispensary. xviii XJST OF CONTEIBUTOHS. WAED, The late STEPHEN H., M.D., Consulting Physician to the Seamen's Ilospitul, Greenwich; and Physician to the City of London Hospital for Diseases of the Chest. WAEDEIiL, J. E., M.D., Consulting Physician to the Tunbridge Wells Infirmary. WATERS, A. T. H., M.D., Physician to the Eoyal Infirmary, Liverpool; Lecturer on Principles and Practice of Medicine at the Liverpool School of Medicine. WEBER, HEEMANN, M.D., Physician to the German Hospital. WELLS, T. SPENCER, President of the Eoyal College of Surgeons ; Surgeon to the Queoii's Household ; Consulting Surgeon to the Samaritan Hospital fcr Women and Children. WILLIAMS, C. THEODORE, M.A., M.D., Physician to the Hospital for Consumption and ' Diseases of the Chest, Brompton. WILSON, sm ERASMUS, LL.D., F.E.S., late President of the Eoyal CoUege of Surgeons; Professor of Dermatology, Eoyal College of Surgeons. WILTSHIRE, ALFRED, M.D., Physician-Acconcheur to, and Joint Lecturer on Obstetric Medicine at, St. Mmy's HoHpital ; Physician for Diseases of Women to the West Loiidou Hi/Kijita.U WOOD, JOHN, F. R. S., Surgeon to King's College Hospital, and Professor of Clinical Sur- gery at King's College. DICTION AEY OP MEDICINE. ABDOHUN, Diseases of the. — Before entering upon the study of the particular diseases ffiach ore liable to be met with in con- nexion with each of the principal regions of the body, it is expedient to regard them from a ge- neral point of Tiew, as such a course helps mate- rially, in clearing the way, for their clinical investigation. This general survey is particularly advantageous in the case of abdominal diseases, which are necessarily very numerous and varied, both as regards the structure affected and the na- ture of the morbid change they present ; they are consequently, difficult to recognise with certainty in many instances, and are occasionally involved in much obscurity. Excluding a few peculiar affections, the dis- eases of the abdomen may be arranged under the following groups : — I. Diseases of the anterior abdominal walls. II. Diseases of the peritoneum and its folds. III. Diseases of the organs contained within the abdominal cavity, namely: — 1, Stomach and Intestines; 2, Hepatic organs, including the liver, gall-bladder, and gall-ducts ; 3, Spleen ; 4, Pan- creas ; 5, Supra-renal capsules ; 6, XTriL'j,ry appa- ratus, viz., the kidneys and their ducts, and the bladder; 7, Pemale generative organs, including the uterus and its broad ligament, the Fallopian tubes, and the ovaries ; 8, Absorbent glands. IV. Diseases of the abdominal vessels, espe- cially the aorta and the iliac arteries. V. Diseases of the sympathetic or othernerves contained within the abdomen. VI. Diseases originating in connexion with the cellular tissue, such as inflammation or abscess. .VII. Diseases springing from the posterior boundary of the abdomen ; from the pelvis or the structures lining it; or from .the diaphragm, and invading the abdominal cavity. VIII. Diseases encroaching upon the abdomen from other parts, especially from the thorax. It must be borne in mind that the groups of diseases above-mentioned may be presented in va- rious combinations, two or more structures being not uncommonly implicated at the same time. The special nature and mode of origin of the diseases thus summarised will be discussed under 1 their appropriate headings, but a few general observations on this subject may prove service- able. Several of the abdominal organs are very liable to so-called functional disorders, being much exposed to the repeated action of various disturbing influences, and these disorders often give rise to prominent and troublesome symptoms, which are urgently complained of by the patient. Definite organic diseases are also of common occurrence, many of them being of a very serious character. Some of the organs contained within the abdomen are subject to malposition or displacement, as well . as to malformations, these being either congenital or acquired ; while the hollow viscera may be the seat of obstruction or accumulations of different kinds ; and each of these conditions may become clinically important. Abdominal lesions are frequently purely ^ocai in their origin, but several of them are but local manifestations of some general condition, being either associated with certain acute febrile diseases, e.g., typhoid fever ; or with some consti- tutional cacliexia, such as cancer. Again, symp- toms connected with the abdomen may depend upon disease in some remote part of the body, oi some of its organs may become the'seat of morbid changes as a consequence of disease in othei structures. For instance, vomiting is frequently associated with cerebral disorders ; while affectionf of the heart are liable to lead to troublesome symptoms, as well as to serious lesions in con- nexion with many of the abdominal viscera. Lastly, a morbid condition of one organ withia the abdomen may be the direct means of originat- ing secondary mischief in other structures. Clinical Investigatioh-.— The clinical exami- nation of cases in which the symptoms point to the abdomen as the seat of mischief should always be conducted with particular care and thoroughness, as well as in a systematic manner, otherwise serious mistakes are liable to be made. It is also very desirable to avoid fonning any de- finite, conclusion as to the nature of tho complaint hastily ^r on insufficient data, but rather to wait and observe the course of events ic .".ry doubtful case, repeating the investigatioij from time to 2 tifiie, when any obscurity which may exist will oilen be cleared away. The past and family his- tory of the patient, with the course and progress of the symptoms, are often of material assistance in diagnosis, and demand due attention in every instance. The chief clinical phenomena which may be associated with abdominal affections, and with reference to which it is requisite to inquire, may be thus indicated. Pirst, there are usually symptoms directly connected with the structure implicated, such as pain and other morbid sen- sations, disorders of secretory or other functions, or excited action. Secondly, several of the organs mutually affect each other, either from being anatomically or physiologically related, or from a morbid condition of one part causing pressure upon or irritation of some neighbouring structure. In this way numerous symptoms are liable to arise, sometimes in remote parts, and often of material significance. Thirdly, sympa- thetic or reflex phenomena in connexion with organs in other regions of the body are frequently excited by many abdominal disorders, such as palpitation of the heart, convulsions, and other nervous disturbances. Fourthly, the general system often suffers seriously; and in various ways. For instance, pyrexia may be excited ; the blood may become impoverished or impregnated with noxious materials ; or more or less general wasting and debility may be induced. Where an abdominal disease is but a local manifestation of some constitutional condition, it commonly ag- gravates materially the general symptoms ; while in connexion with lesions of certain of the ab- dominal viscera these general symptoms consti- tute in many cases the most prominent clinical features. Fifthly, morbid conditions within the abdomen not unfrequently interfere directly with the diaphragm and the thoracic organs ; occa- sionally also they invade upon the chest, or actually make their way into this cavity through the diaphragm. In rare instances morbid pro- ducts, such as pus, may find their way to distant parts of the body. In these different ways a variety of symptoms may be caused, sometimes of a curious nature and diificult to explain. Lastly, abdominal diseases are frequently at- tended with abnormal physical or objective signs, which are revealed on physical examina- tion, and these are of such importance that they demand separate consideration. Phtsioai. ExAMiNATioif. — The neglect of submitting patients to a satisfactory physical examination is a frequent source of error in diagnosis in cases of abdominal disease, and there ought to be no hesitation or delay in resorting to this method of clinical investigation whenever it seems called for. The precise course to be pursued must vary according to cir- cumstances, butthe following outline will serve to indicate the plan of procedure ordinarily required. First, there are certain modes of examination which are applied to the abdomen externally, including Inspection; Palpation or Manipula- tion; Mensuration or Measmremait ; Percussion; and Auscultation (see Physical Examina- tion). Of these, inspection, palpation, and percussion are by far the most important, and have, in the large majority of cases, to be relied upon for the information required. In ex- ABDOMEN, DISEASES OF THE. ceptional instances Succussion or shaking ;he patient proves serviceable, by bringing out cer- tain sensations or sounds. In order to carry out these methods properly, it is necessary to expose the abdomen sufficiently, due regard being paid to decency in the examination of females ; to place the patient in a suitable posi- tion ; and to see that the muscles of the abdo- minal walls are duly relaxed. The best posi- tion usually is for the patient to lie on the back, in a half-reclining attitude, with the head and shoulders well raised, and the thighs and knees more or loss flexed. This posture serves to relax the abdominal muscles, whidi may be further aided by taking off the patient's atten- tion by conversation or in other ways,. as well as by directing him to breathe deeply. The posi- tion, however, has often to be varied in the investigation of particular cases, and much information is frequently gained by noticing tlie effects of altering the posture. The objective conditions which may be revealed by the modes of examination thus far con- sidered are as follows: — 1. The state of the superficial structures. 2. The size and shape of the abdomen, generally and locally, as indi- cating an alteration in the volume of the ordinary contents of the abdomen, or the presence of some new or fresh element, such as dropsical fluid or a tumour. 3. The characters of the abdominal respiratory movements ; and the pre- sence of any unusual sensations during the act of breathing, such as friction-fremitus. 4. The sensations experienced on palpation and percussion over the abdomen, either as a whole, or in any particular part of it, such as its mobility, degree of resistance, regularity, con- sistence, &o. ; as well as the presence of cer- tain peculiar sensations, e.g., fluctuation, or hydatid-fremitus. 5. The presence and cha- racters of any pulsation. 6. The occurrence of abnormal movements within the abdomen, as those of a foetus. 7. The sounds elicited, gene- rally and locally, on percussion. 8. The pre- sence of certain sounds within the abdomen, heard on auscultation, such as friction-sounds ; murmurs connected with aneurism or due to pressure on an artery ; or murmurs and sounds associated with the pregnant uterus. Secondly, it not uncommonly happens that special modes of examination have to be applied to particular organs within the abdomen, in order to arrive at a diagnosis with any cer- tainty. And here it may be remarked that it is highly important in all cases to see that no accumulation of faeces exists within the bowels, and that the bladder is properly emptied, other- wise very serious mistakes are liable to be made. Purgatives and enemata are needed in order to remove any faecal collection. The urine should also be properly tested in every instance ; and much information may often be gained in the in- vestigation of affections of the alimentary canal, from a personal inspection or more complete examination of faeces or vomited matters. The abdominal organs to which special modes of examination are chiefly applicable are the female generative organs, which are investigated per vaginam (sec Womb, Diseases of) ; the bladder, by means of the catheter, the sound, and other ABDOMEN, DISEASES OF THE. surgical instruments ; the stomach, by the use of the stomach-pump, probang, &c. ; and the in- testines, by examining with the finger, hand, or surgical instruments per rectum, or by injecting •water or air through the anus into the bowels. The ordinary modes of examination already men- tioned may afford assistance when employed along with some of the special methods just indicated. Thirdly, occasionally it is requisite to have recourse to exceptional modes of investigation, such as the use of the exploring trochar or aspi- rator; or to the administration of chloroform. The latter may afford direct information in certain abdominal conditions, and it may also materially assist in carrying out other methods of exploration. The abnormal conditions discoverable by physical examination may involve the entire abdomen, giving rise, for instance, to general enlargement or retraction; or they may be limited to some particular region, e.g., enlarged organs, tumours, or abscesses. This part of the body has been artificially divided by anatomists into regions, and the seat of any local morbid condition can thus be defined and described. The diseases peculiar to the several regions will be considered under their respective headings. Fbbderick T. Bobebts. ABDOMINAL AWETIKISM includes aneurism of the aorta, and of any of its branches within the abdomen. Aneuxism of tlie Abdominal Aorta is essen- tially a disease of middle age. Of fifty-nine cases collected by Dr. Crisp, thirty-three were under the age of forty. It'ismore common in the male than in the female sex in the proportion of about 8:1; and is usually traceable to strain, or to a blow upon the abdomen or back. The aneu- rism is most frequently located in that portion of the vessel included between the aortic open- ing in the diaphragm and the origin of the superior mesenteric artery. In this situation the tumour is deeply seated; liable to tension from the crura of the diaphragm ; and likely to involve the great splanchnic nerves, the semilunar gan- glia, and the solar plexus. Hence the occasional difficulty of diagnosis; and the frequency of boring pain in the back from erosion of the vertebrje, and of paroxysms of radiating pain in the abdominal viscera from stretching of the adjacent nerves. When situated lower down :n the course of the aorta, the disease is less obscure, and the symptoms are less urgent. Aneurism of the abdominal aorta is usually of the/fflZse variety; and, as contrasted with thoracic aneurism, it is less often associated with extensive atheroma of the aorta, and with fatty or other structural disease of the heart. The symptoms referable to excentric pressure are also fewer, and, with the exception of pain, are less urgent. Symptoms akd Signs. — Of the symptoms, ^om is the most characteristic and the most urgent ; it is of two kinds, which are not, however, neces- sarily associated. In its usual form the pain of abdominal aneurism is essentially neuralgic ; it is intermittent and paroxysmal,^-radiating through «he abdomen, bati, pelvis, and base of the thorax, and not unfrequently into either groin or testicle. The a signifies scurf, or dandruff; itx^P^" mean- ing chaff. Erasmus Wilson. ACHOEION (ix^Pi BCurf) is the name given to one of the three principal dermophytea or epi- phytes of the skin. It is the constituent of the crusts of Favus (Achor), andbelongs to the group of fungoid plants denominated OirfiMm. It consists of spores, sporidia or tubes filled with spores, and empty branched tubes or mycelium. Achoriun was the first discovered of the epi- phytes of the skin, and in compliment to one of its early observers, Schonlein, has been n&medAcho- rbn SchSnleinii. It is supposed to be the agent of contagion in Eavus ; it has also been found in the loose cell-structure beneath the nail in Ony- chogryphosis. Eeasmus Wilson. ACHHOMA (o, priv., and xp^P-a, colour). Absence of colour ; an achromatous or colourless, state of an usually coloured tissue, due to absence of pigment. In reference to the skin Achroma is synonymous with Leucoderma, Albinism, and Alphosis. See Pihmentaet Skin-Diseases. AOHBOMATOPSIA (a, priv. ; XP"l"h colour; and Sf, sight). — ^More or less complete inability to distinguish colours from each other. See Vision, Disorders of. ACIDITY. — Acids are constantly passing out of the body by the lungs, the skin, and the kid- neys. These acids, if we except the small quantity introduced from without in the form of acid salts of certain articles of food, are formed within the body by the disintegration and oxidation of the tissues and food. If the oxidation of organic substances in the system were complete, the sole products of their combustion would be carbonic acid, water, and urea ; but as this oxidation is never actually complete, other products, as lactic acid, oxalic acid, uric acid, etc., are formed ; and the increased or diminished production of these intermediary products may be regarded as the measure of the completeness with which the ox- idation processes are being performed in the body. The quantity of acid matter passing through the blood on its way to the lungs, the skin, and the kidneys is considerable; since it has been shown approximatively, that a healthy man of eleven stone weight, under ordinary cir- cumstances, passes by the two first channels an average of 890 grammes (about 28 ounces) of carbonic acid daily, and that the acid excreted by the kidneys in the same period is equiva- lent to two grammes (about 31 grains) of crystal- lised oxalic acid ; whilst the volatile fatty acids passing off with the sweathave notyet been satis- factorily calculated. It is evident that if the re- gular elimination of this acid, by any of these channels, be interfered with, it will tend to ac- cumulate in the system. Acidity, or excess of acid in the body, therefore depends on two causes : — 1. Excessive formation,.the result of incomplete oxidation of the elements of the tissues and the food. 2. Deficient elimination of acid formed either in normal or abnormal quantities. Both these causes, however, are generally found acting in conjunction. Oxidation is imperfectly per- formed, when an insufficient quantity of oxygen 10 ACIDITY. is introduced into the body, owing to insuffi- ciency of the respiratory act, the result of disease or of sedentary habits ; or when the blood is poor in red corpuscles, the carriers of oxygen, as in leucocythsemia ; or from functional derange- ment of some lajge gland, as the liver, where oxidizing processes are extensively wrought. Again, the materials submitted to the influence of the oxygen within the body may be so in- creased, as is the case in febrile conditions, or in general plethora induced by over-feeding and insufficient exercise, that the supply of oxygen may prove insufficient for their complete com- bustion. Defective elimination of the acids formed within the body is due either to dis- eased conditions which prevent, or to want of the physiological stimulus which excites, the lungs, skin, and kidneys to exercise their re- spective functions properly. It will be seen, therefore, that acidity may arise in consequence of the disturbing influence of disease ; or may be acquired or inherited as the penalty of trans- gression of certain laws of health — as the result of unfavourable hygienic conditions. In the former ease, acidity is only' secondary, and is generally subordinate to the disease producing it, and has rarely to be considered apart from it; whilst in the latter instance' acidity is usually at first the only trouble, leading, however, if dis- regarded to secondary mischiefs. Effects. — The mucous membranes and skin chiefly suffer in acidity. The former become subject to catarrh, produced, no doubt, by the irritating presence of the acid. Acidity may thus cause bronchitis, gastro -intestinal catarrh, and catarrh of the genito-urinary tract. Some- times the acid is poured out in such quanti- ties from the mucous membrane of the stomach as to be ejected from the mouth. In these cases digestion is considerably interfered with by the too acid condition of the gastric juice. Some- time^, however, this acidity of the stomach is produced by an opposite condition — the defi- ciency of the digestive fluid, and consequent acid fermentation of the food. Abnormal acidity of the urine produces not only catarrh of the urinary passages, but by decomposing the salts of uric acid causes a deposit of insoluble uric acid in the passages, thus giving rise to attacks of gravel or leading to the formation of, a calculus. Acidity manifests itself in the skin by attacks of erythema, herpes, eczema, and urticaria. Eheu- matism, too, may be considered as a disease resulting from the formation of acid, affecting chiefly fibrous and serous membrane; no one can witness the enormous quantities of acid sweat poured out, and the highly acid urine, in the acute form of ' this disease, without acknowledging that an increased formation of acid is taking place somewhere in the body; though perhaps unwilling to commit himself to accept any of the views hitherto advanced as to the nature of the acid. Estimation of Acid. — ^For clinical purposes an estimation of the acidity of the urine fur- nishes the physician with an approximate clue as to the amount of acid formed in and passing out of the body. This is done by collecting the urine for twenty-four hours, placing 100 c.c. of this in a beaker, and then adding a solution ACIDS. of sodium hydrate, standardised so that 1 c.c, = "01 gramme of crystallised oxalic acid, from a Mohr's burette, till the fluid is neutralised ; tho number- of cc.'s of the standard solution required to effect this is to be multiplied by '01, which gives the percentage acidity in terms of o-xalic acid ; to ascertain from this the total amount of acid in the twenty-four hours' urine is only a matter of calculation. Too much dependence must not, however, be placed on the urine as a means of estimating excess or deficiency of acid tn the sys- tem ; it sometimes happens that in highly acid conditions the urine is alkaline. This, as Dr. Bence Jones has shown, may occur when large quantities of acid fluid are poured out of the stomach ; and Prout long ago observed, that in the eczema of gouty persons the urine, so long as the disease persisted, was either of low acidity or alkaline, but that the subsidence of the eczema was frequently followed by an over-acid condition of the urine, accompanied with renal and vesical catarrh. TEEA.TMENT.-^Th6 general indications for the treatment of acidity consist in the promotion of oxidation, and the eliminatjonof the acids formed. Active habits, which promote the pulmonary and cutaneous functions, should be encouraged. The diet should be just sufficient to meet the physio- logical requirements of the body ; it should con- sist chiefly of fish, fowl, game, and eggs ; sac- charine and farinaceous articles being excluded. Sweet and cheap wines should be avoided ; for those who cannot afford to purchase good wine, pure spirits and water is the best substitute. Carlsbad salts or Friedrichshall water may be given if there is much abdorainal plethora; the habit of taking mercurials as a relief for this condition is to be deprecated. Alkaline medi- cines are frequently administered with a view of neutralising the effects of acid; their employ- ment for this purpose seems, however, question- able. Dr. Parkes has stated that the adminis- tration of bicarbonate of potash (a favourite remedy in acid diseases), though rendering the urine alkaline, in reality increases very largely the excretion of the organic acids. This is not to be wondered at when we consider that the bicarboiiate, although aUcaline in reaction, is in constitution an acid salt. The nitric and hydro- chloric acids, given in moderate doses about one hour before meals, certainly have a powerful oxidising effect, and diminish the quantity of uric acid excreted in the urine. In cases where the acidity is manifestly due to defective oxida- tion consequent on poverty of blood from dimi- nution of the red corpuscles, iron and food must be freely given. ACIBS. — ^^ Definition. — Substances which combine with alkalis, and destroy their power of turning red litmus paper blue. Most of the acids also redden blue litmus, and have a sour taste ; but some, for example, carbolic acid, possess neither of these properties. Encmbeation Acids may be divided into Inorganic or Mineral, and Organic. The mine- ral acids used in medicine are Carbonic. Hy- drochloric, 'Nitric, Nitrohydrochloric, Phos- phoric, Sulphuric and Sulphurous acids. Tho organie adds thus employed include Acetic ACIDS. Benzoic, and Ciirbolio, Citric, Gallic, Hydro- cyanic, Lactio, Salicylic, Tannic, Tartaric, and Valerianic. AoTjoN.TT^The stronger acids — Sulphuric, Ni- tric, Hydrochloric, and Glacial Acetic acids — destroy animal tissues, and act as caustics when applied to the surface. "When swal- lowed, they produce the symptoms of irritant poisoning. (Sec PoraoKS.) An antidote for these poisons which is always at hand is carbonate of lime, in the form either of whiting or of plaster chipped from the nearest wall. Other antidotes are alkaline carbonates and bicarbo- nates, milk, oil, and soap. Diluted acids, taken into the mouth, increase the secretion of saliva ; and hydrochloric acid forms an important con- stituent of the gastric juice, without which digestion does not go on. When absorbed into the blood, dilute acids act on the heart gene- rally, slowing its pulsations and reducing the temperature. They are excreted in the urine and milk.. Uses. — Nitric acid is employed as a caustic application to piles, to poisoned wounds, and to spreading or unhealthy sores. Glacial Acetic acid is used to destroy corns or warts. Diluted Acetic acid or vinegar is applied as a lotion to relieve headache ; to allay the itching of prurigo, lichen, and psoriasis ; to check perspiration ; and sometimes to hasten the appearance of , exan- thematous eruptions. Diluted acids, especially Citric, Tartaric, and Hydrochloric, are adminis- tered in fevers as refrigerants, because they relieve the dryness of the moutli, and diminish the thirst by increasing the secretion of saliva, as well as lower the temperature and pulse- rate. Under the like circumstances, the organic acids, Acetic, Citric, and Tartaric, when com- bined with alkaline carbonates in a state of effervescence or otherwise, form agents which act on the skin and. kidneys. In febrile con- ditions, ansemia, and some forms of dyspepsia, the proportion of acid in the gastric juice is insuffi- cient for the proper digestion of food, and the administration of diluteHydrochloricacid, imme- diately before or after meals, is useful both by aiding digestion and by preventing the formation of butyric and other acids, which give rise to sour eructations. Nitro-hydrochloric acid, before meals, is likewise beneficial in preventing acidity. It appears to have some action on- the liver, and is used both internally and externally as a lotion or footbath in jaundice and biliousness. It generally relieves the frontal headache common in young females, which is felt just above the eyebrows, and not. accompanied by constipation. Dilute acids, especially Ajomatio Sulphuric acid, are useful in checking diarrhoea, colliquative sweats, hsemorrhages, and mucous discharges. By lessening the alkalinity of the urine, they tend to prevent the formation of phosphatic cal- culi, phosphoric and nitric acids being most fre- quently employed for this purpose. Care must be exercised in their administration to nursing mothers, as they are excreted in the milk, and sometimes cause griping and diarrhcea in infants at the breast. Several acids have a special action of' their own, and are consi- deiod under their respective groups, such as Hydrocyanic acid, which is a sedative ; Carbolic, AONE. 11 an antiseptic ; Salicylic, an apyretic ; Gallic and Tannic, astringents. T. Lauceb Bbchton. AOINESIA (i, priv., and kIi/ijiTis, motion).-^ A synonym for paralysis of motion, whethei partial or general. See Pabalysis, Motoe. AONE {lMiid(», I bloom). — The ancient Greeks showed their appreciation of the mor- .bid states of the integument by calling this disease luefial, the flos istatis of their Latin trans- lators ; but in course of transmission the n gave place to I*, and the original term to that by which the disease is at present known. Definition. — An inflammation of the hair follicles, or a folliculitis of the skin, associated with the development of the permanent hair of the body at and after puberty ; its almost exclu- sive seat of manifestation being the face, the submastoid region of the neck, the sternal region of the breast, and the back and shoulders. .SlTiOLoaT and PATHOLoaT. — In its relation to other diseases of the skin. Acne is nothing more than a folliculitis; and folliculitis, how- ever engendered, must always pursue the same pathological course. Hence folliculitis of the face, from whatever cause, especially if at- tended with papulation and suppuration simi- lar to the acne of puberty, has . likewise been termed Acne ; such is the Aciie Bosacea or Gutia Eosacea of adult life ; and such are the varieties of folliculitis produced by iodine, bromine, and tar, which have been respectively denominated Iodine-, Bromine-, and Tar-Acne. Desckiption. — The pathological essentials of Acne are : — a languid and torpid skin ; a tendency to accumulation of sebaceous matter within the follicles ; congestion of the coats of the follicles and immediately contiguous structures ; and the ordinary manifestations of inflammation, such as suppuration, inflltration, and solidification. Prom thes6, which are the ordinary signs of inflamma- tion of the follicles, we derive the various sub- jective designations of the disease : for example, when accumiilation of sebaceous matter, showing as a black point with little or no inflammation, is the leading feature, the condition is termed A(mo punctata ; when congestion and infiltration force up the skin into a conical pimple, Aone coni- formis ; when suppuration is present. Acne pus- tulpsa; and when thickening and condensation display themselves. Acne indurata. The whole series, with the exception of Acne indurata, which represents a chronic disposition, may bo called indiscriminately Aone simplex or Acn^ vulgaris, there being obviously no regular standard. DiAONOSis. — ^Acne is a well-defined eruption, and not difficult of diagnosis, its most im- portant features being: — its limitation to the period of life corresponding to and soon after puberty; and its dependence on a phy- siological process at that time taking place in the economy. Tbeatmeni;. — The treatment of Acne may be summed up in a few words : — Eemove any ex- citing cause that may exist ; improve the nutri- tive power of the individual and of the skin ; stimulate, that is, give tone and vigour to the part locally. Dur best general remedies aie n 12 AONE. good hygiene, laieful attention to diet and habits of life, ordinary tonics, and especially arsenic. The most efficient local application is sulplinr, especially the componnd hypochloride of sulphur ointment, which consists of a drachm of hypochloride of sulphur -with ten grains of carbonate of potash, to an ounce of benzoated lard. Arsenic is best administered as a com- bination of Vinum Perrl and Liquor Arseni- calis (wiij-iij) three times daily at the end of meals. EsASMns Wilson. ACOWITB, FoiBonmg by. — See Poisous. ACQ,TTIB:ED diseases. — Diseases origi- nating independently of hereditary transmission. See Disease, Causes of. ACBOCHOEDOH. — An outgrowth of the integument in the form of a slender cylinder, which may be compared to the loose end of a piece of string or cord — &Kpoy signifying a point or end and x<>P^h b, string. Such out- growths are usually met with in a feeble state of the skin, and particularly in elderly persons, their common seat being the neck or trunk. They are at first sessile, but become elongated ; and are sometimes bulbous at the extremity, and more or less pedunculated. Pathologically an acrochordon is composed of loose areolar tissue, firmer at the surface than within, and of a fine artery and Tein, connected by a capillary loop or plexus, and sometimes a little ramified. It is popularly regarded as a wart, and in medical works is termed verruca acrochordon, but it differs from a wart very widely in structure. When acrochordones attain a size beyond that of a pea, they fall into the category of a soft tegumentary tumour or Molluscum, Tbeaxh£NI This consists in snipping them off with scissors, or touching them with a strong solution of potassa fusa (equal parts). When numerous and minute, they admit of being shri- velled up and removed by means of liquor plumbi, or a lotion of perchloride of mercury, two grains to the ounce. The latter, by its stimu- lating property, also arrests their formation. Ebasmds Wilson. ACBODYITIA (&Kpos, extreme, and oSivri, pain). A dermatitis affecting the hands and feet, particularly the palms and ' soles, accompanied with burning heat, stinging and smarting pains, and numbness. The pains some- times extend to the whole system, and there iis more or less disorder of the <£gestive and assimi- lative functions. The redness is at first bright, then deeper tinted an(J brown, with considerable pigmentation of the rete mucpsum. Occasionally there are pimples, pustules, and blisters ; the cuticle desquamates, and is sometimes cast in a single piece ; the disease tunning on for several Teeatment. — This should be directed to the regulation of the digestive and assimilative or- gans, and to the relief of local inflammation by means of water-dressing followed by bandaging with zinc ointment. Ebasmus Wilsok, ACUPUNCTUKB is an ancient mode of iicAtment for the relief of painful affections, now ADDISON'S DISEASE, but little used, consisting in the introduction of fine round needles through the skin, to a varying depth. It is said to have been introduced into thib country from China or Japan, about 200 years ago. The needles used are about two inches in length, and are set in round handles, so that they can be introduced with a gentle rotatory movement. It is now employed solely in lumbago and seiarica, in which affections it undoubtedly gives relief. The operation is thus performed. The patient being laid upon his face, tender spots are sought for — in lumbago over the erector spinse, and in sciatica along the course of the sciatic nerve. The needles are then pushed in vertically for a depth of from one and a-half to two inches, and allowed to remain for from half an hour to two hours. The number of needles employed may vary from one to six. In sciatica it is recommended, if possible,' to make the needle actually penetrate the' nerve. This is known , by the patient complaining of sudden pain shooting down the back of the leg. The mode of actioii is uncertain, but in sciatica it has been supposed that the puncture of the nerve sheath, allows the escape of fluid. Acupuncture has also been employed in painful neuritis following injury, but without much effect. In a modification invented by Baun- scheidt, forty punctures, about half-an-inch in depth, were made in an area of the size of » crown piece, by an instrument working by a spring. Oil of mustard diluted -with olive oil was then painted on, which gave rise to an eruption like herpes. This was at one time in great repute as a quack remedy for all sorts of diseases. The term acupuncture is also applied by some to the introduction of needles into a cyst, in order to allow the fluid contents to escape, as in the treatment of ganglion, of hy- drocele in infants, or of hydatid cyst of the liver. Puncture . of the skin for the relief of oedema or subcutaneous emphysema is some- times called by the same name. For this pur- pose the ordinary three-cornered acupressure needle is more convenient than a round acu- puncture needle, as the puncture resulting from it allows fluid to escape more readily. Mahcus Beck. AOTTTB.— -This word, when associated with a disease, signifies that such disease runs a more or less rapid course, and is generally attended with severe symptoms. It is also employed to express intensity of a particular symptom, as, for example, pain. ADDISOIJ-'S DISEASE. Stnon. : Morbus Addisonii; Bronzed Skin. Disease. Fr. Ma- ladie d^ Addison ; Ger. Addisonsche Kranklieit. Defikition. — In his original memoir on this subject. Dr. Addison wrote—' The leading and characteristic features of the morbid state to which I would direct attention are anaemia, general languor and debility, remarkable feeble- ness of the heart's action, irritability of the stomach, and a peculiar change of colour in the skin occurring in connection with a diseased condition of the supra-renal capsules.' In reality, the general symptoms of the disease, as given above,, outweigh in import- ance any pigmentary change whatever ; and it ADDISON'S DISEASE. 13 Is quite possible for the disease to ran its course wilJiout any unusual deposit of pigment in any part of the body. Addison's disease might, howerer, be defined as 'a constitutional malady characterised by great weakness and ansemia, -with deposit of pigment in the skin and some other parts of the body, and accompanied by or depending on a specific morbid change in the supra-renal capsules.' Etiology. — The constitutional or general nature of the malady must ever be borne in mind, though some of its factors are strictly local ; but, though constitutional, it is not trans- missible either (o) by contagion or infection, or (J) by inheritance. If, however, Addison's disease itself is never an inherited malady, it is in very many cases associated with a highly hereditary constitution, that of the tubercular or scrofulous type, and in such individi\als ac- cidents like falls or blows, which would fail to make an impression on stronger men or women, may sufBce to set the morbid process in motion. In not a few instances the bodies of the sub- jects of this disease have been found perfectly healthy apart from the morbid change in the supra-renal capsules characteristic of the malady; and, in a certain number of cases, local abscesses seem to have been the starting-point of the specific changes in the capsules themselves. Addison's disease is, moreover, essentially one of eatly adult life, the great majority of cases occurring between fifteen and forty. It is much more frequent in men than in women, and seems, in a great measure, to be confined to the working Classes. Symptoms. — It is not at all times nor in all instances an easy task to make out a perfect clinical history in a case of Addison's disease. The earlier symptoms are often so indefinite and so insidious that it may not be until the disease is fully developed that the patient seeks medical aid, and by that time the symptoms are usually unmistakeable. It is different when the malady apparently originates in a fall or a blow, but even such a starting-point as this may only be sought for late in the history of the disease. The mischief may. be said to commence in most cases with a feeling of general weakness and of being unwell ; the discolouration of the skin usually appears later, but may be the first prominent symptom.' In a small number of cases the onset may be acute, with loss of appetite, sickness, headache, pain in the epi- gastrium, sometimes also vomiting and diar- rhoea. When the disease has attained its full development the characteristics of the malady are most striking. Then the downcast, mourn- ful look, the drooping shoulders and stooping gait, the arms hanging helplessly by the sides, and the slow and listless movements of the patient are strikingly impressive. If to this be added the darkening of the skin, the clear and pearly conjunctiva, and the breathlessness on exertion, we have almost all that meets the eye when such a patient presents himself. But to these, on enquiry, other important symptoms are .easily added. The 'breathlessness - will be found to be partly due to ansemia, partly to impaired innervation. From the same causes in part, but not entirely, we find a quiet, feeblo action of the heart, readily giving place to pal- pitation. With these are usually associated pain and tenderness in the epigastrium and hypo- chondria, irritability of the stomach and nausea giving rise to retching, and frequently obstinate vomiting. Such modifications of breathing as sighing, yawning, or hiccup, are frequent. Again, from the ansemia, there is a strong tendency to giddiness and syncope, which last in creases as the disease wears on, and, in many cases, carries oS the patient when raising iiimself, or being raised in bed for the purpose of taking food or perform- ing other necessary functions. This is not the invariable mode of death, for nervous symptoms, such as coma or convulsions, may usher in. the final scene. When the prostration is great, .the patient may be for some time before death ap- parently unconscious, but this is simply due to unwillingness to make the slightest exertion, owing to his profound weakness. Throughout the whole disease the bodily tem- perature is diminished(97°-98° Fh.) rather than increased, and this is often markedly the case towards the close of the disease; though then it has been noted as high as 100-8°Fh. From the above sketch it is plain that the two most prominent factors in the disease, as presented during life, are — 1 St. General weakness and ansemia. , 2nd. Abnormal deposit of pigment in various parts of the body. 1. To the former of these is to be referred (a) the loss of muscular power, as evidenced by diminished muscular energy and force both in the voluntary and involuntary muscles, for the heart's action is feeble and imperfect, and the bowels are usually confined. (A) At once a cause and consequence of the weakness and ansemia are loss of aj^etite, sickness and vomiting, though these, too, depend in part on other morbid changes ; whilst, lastly (c), imperfect nutrition of the nervous system results, notably of the brain itself, whence arise vertigo, numbness, dimness of sight, deafness, tremors, and the like. The pain in the epigastric and hypochondriac regions is probably due to local causes. 2. The deposit of pigment is peculiar and characteristic. It is not uniform in disposition, . and varies greatly in tint. It may only amount to a light brown or smoky discoloration in cer- tain parts, or it may assume the appearance of a dark olive-green hue, approaching to black in some situations, especially over the genitals and nipples. Elsewhere it is most abundant on the face, where it often seems to begin, on the neck, the backs of the hands, the folds of the legs, and along either side of the linea alba. A striking peculiarity is that the conjunctivae are clear and pearly, and that the nails are never discoloured. On the other hand, there is a great tendency to the deposit of pigment where the skin has been irritated or -the epidermis removed, as bjr a mustard poultice or blister ; but the skin is always' smooth and supple. In a typical case under the .-writer's care, blisters had been applied: to the chest for the uneasy feeling ex- perienced there, and here the pigmentary tint was deeper than in any other part of the body, save the genitals. Cicatrices affecting the whole u ADDISON'S DISEASE. depth of the skia do not seem to be so pig- mented. The mucous membrane of the mouth not unfrequently becomes the site of pigmen- tary deposits. These are not diffiise, but, 'vrhen the lips are affected, they usually take the shape of smears or lines. On the insides of the cheeks blotches or irregularly-defined spots are most common, as veil as on the sides and root of the tongue. The latter spots are commonly better defined than are the others, and some- what resemble the small irell-marked black spots occasionally observed in parts already pigmented. The site of this pigmentary deposit is m the growing layer of the epidermis, the usual eite of colour in all races of mankind, and 'which is usually known as the rele mttcosum ; but occa- sionally pigmentary granules are to be found deeper, in the cells of the true skin. An interesting clinical fact has been brought out by Dr. Greenhow, which will, probably, be noted in a considerable proportion of cases. This is the mode in which the disease pro- gresses. Often it presents periods of remission, only to be followed by a more marked ad- vance ; but, notwithstanding these remissions, the progress is invariably towards a fatal termina- tion. The time occupied in this progress varies much ; it may be weeks or months, or it may be years, but in all well-defined cases the result is the same. Pathology. — From the earliest description of the morbid state known as Addison's disease, the malady has been associated with disease of the supra-renal capsules. At first it was sup- posed that any form of disease affecting these organs must give rise to a similar train of symptoms, and some of the investigations car- ried on with a view to sustain this position sound absurd enough by the light of subsequent experience. Gradually it has been made clear that only one kind of lesion is accompanied by the specific symptoms just detailed. Briefly, the morbid changes are as follows : — Normally, the supra-renal capsules consist of two parts, a cortical and medullary, differ- ing greatly in their structure. In Addison's disease both are superseded by a new structure, which is to be seen in various stages. In the earliest of these the capsules are invaded by a kind of translucent material, which is some- times almost cartilaginous in its hardness, and which, when examined under the microscope, resolves itself into a kind of very finely fibril- lated or trabecular connective tissue, with cor- puscles like leucocytes freely congregated in the interstices of the meshwork or between the fibres. This material, when seen in bulk, is grey or greenish-grey, afterwards becoming red on exposure. With it is mixed up an opaque yellow substance, varying in amount and appa- rently more abundant the more advanced the disease. In the earlier stages it presents the appearance of nodules embedded in thef trans- lucent material, but later almost the whole of this last may have disappeared, and the yellow opaque matter become converted into a thick creamy fluid, a putty-like substance, or even one or more cretaceous masses. This opaque mate- rial, then, is evidently, from its first appearance, indicative of fatty degeneration, and closely re- sembles in every respect what used to be known as yellow or crude tubercle. The exterior of the capsules presents certain important features. The capsules themselves may be large or small, according to the stage of the disease and the nature of their contents, hut, even when they are small, it may be safely as- sumed that at one time they were enlarged. In all cases they will be found closely and strongly adherent to neighbouring structures.- Some of these structures are of great importance : ,for example, the semi-lunar ganglia, and the vast plexus of nerves associated therewith, in which important changes have been found. These pa- thological conditions have been so often observed and so carefully noted, that they cannot be looked upon as accidental concomitants of the diseased process, but rather part and parcel of it, and, in all probability, as giving a due to some of the most marked phenomena of the malady. Broadly it may be said that these changes consist in a great thickening of the connective tissue surrounding the nerve-fibres and the ganglion-cells, giving rise to something like compression and ultimate destruction of the nerve cells and fibres. This occurs both in the cerebro-spinal nerve fibres and in those more intimately connected with the ganglionic system. The nerve-cells, moreover, are not unfrequently deeply pigmented. These, so far as is known, constitute the main pathological elements of Addison's disease. It does not arise from mere destruction of the supra-renal capsules, for then it would be seen under other conditions, as when cancer of a neighbouring organ extends to and involves the supra-renals ; but no Addison's disease follows this event. The exact mode in which these nerve lesions give rise to the characteristic symptoms of the disease are, as yet, matters of speculation, and not of exact science; and it may be said that our knowledge of the whole of this subject is yet in its infancy. Though these are the main facts relating to the pathology of Addison's disease, there are still others of some importance. Pigmentation has been sufficiently noticed, but its origin has not been discovered. Without doubt the pig- ment, like other animal pigments, is derived from the blood, and this has been examined with a view to discover any change in its composition which would explain the darkening of the skin, but without result. In making the section of the body of one who has been the subject of Addison's disease, one cannot help being struck with the amount of sxibcutaneous fat, especially over the abdo- men, as contrasted with the diflSculties of nutrition under which the patient, sufljered ; yet a considerable quantity is almost always found. But more closely connected with this malnutri- tion are certain changes in the absorbent system along the digestive tract. These consist in enlargement of the solitary and agglomerated glands constituting Peyer's patches, and of the mesenteric glands; as well as of lymphoid de- posits in the mucous membrane of the stomach which give rise to little projections, termed mam- miUaiions, on the walls of that organ, especiallv ADDISON'S DISEASE. near the pylorus. Small eochymoses are also not uimsually found in the same situation. Of other organs it may be noted that the liver and spleen are often enlarged and hypersemic, and the heart small and light. Diagnosis. — There -would have ^been less diffi- culty or doubt in the diagnosis of Addison's disease, had it been clearly enunciated from the first that a bronzed skin did not . alone oon- ttitute the malady. The disease rests on a threefold basis — general weakness, disecsed supra- renal capsules, and bronzed skin, the last being the least important of the three. There may be darkening of the skin from a great variety of causes, viz.: (a) exposure, and attacks of vermin {morbus Beonum, Greenhow; Vaganien KranhMt, Vogt); (4) -wasting diseases, as chronic phthisis; (c) syphilis; (d) malaria; («) liver disease or jaundice if long-continued ; &c. ; but in none of these cases should there be any difficulty if the preceding dictum is borne in mind. i Peoqnosis. — This is always unfavourable, but it is impossible to assign any definite period for the termination of the disease, sini;^ it often pro- gresses irregularly, vrith periods of improve- ment followed by relapse. Tebatment. — From what has just been said it is plain that not much is to be effected by treatment as regards the cure of the disease, but much may be done by carefcl manage- ment to retiird its progress and opmfprt the patient. As soon as the disease is discovered, the sooner the patient makes up his mind to an invalid life the better. Eest and careful dieting are the basis of the treatment. As re- gards diet, it may be briefly said that what the patient can take best suits, best. , As the stomach is so irritable, anything likely to upset it should be avoided. Hence, as a rule, it is better to give concentrated nourishment, as essence of meat {not the extract) or chidcen, or raw pounded meat, yrhen other things cannot bo taken. It is also important to bear in mind that the stomach will often tolerate food cold or even frozen, when hot substances would be promptly rejected. In certain stages of this malady it may well be said that the physician's success will depend more on his. knowledge of the cookery book than of the Pharmacopoeia — not, however, that our phaiTiaceutical gifts are to be despised. For the profound depression stimuLints will be necessary, but these may take the shape of ether or spirits of chloro- form, as well as of wine or brandy. For the irritable stomach, alkalies, with nux vomica and ipecacuan, or, calumba, are of great service. So, too, in another way, are light tonics and i^eutral salts . of irpn ; but the stomach should not be clogged with too much medicine. The bowels should not be much disturbed, but, if an aperient be required, a mil,d one, as a small dose of castor oil, or the compound liquorice powder of the Prussian Pharmacopoeia wUl suit, if the stomach does not rebel ; if so, a wineglassful of Hunyadi Janos water the first thing in the morning, followed by a cup of warm milk, may better agree with the irritable organ ; when there is diarrhtea, a totally diiferent line of treatment will be necessary. But in all ADHESIONS. 16 things, and at all times, the grand rule is to save the patient's strength, to add to it if pos- sible, and to resist the inroads of the disease whatever shape these may assume. AXHXANDEB SlLVEB. ADEWALaiA (4SV, a gland, and KX701, pain). — Pain in a gland. ADENITIS.— Inflammation of a gland. See the several glands. ASENOCELE (oSV, " gland, and k^\i), a tumour). — A tumour connected with a gland. ADEKTODYITIA (iSVi a gland, and AS^Mj, pain). — Pain in a gland. ADEDITOID (oSV. a gland, and «fSoJ, form). — Glandular : . resembling the structure of a gland, whether secreting or lymphatic. ADBWOMA (48V, a gland, and itibs, like). — A morbid growth, the structure of which is of glandular nature. See Tumours. -Structures are said to be ADHERENT. \ ADHESIONS. J" adherent when they become abnormally united together, the morbid formations by which this union is effected being termed adhesions. These are most frequently met with in connection with serous surfaces, Being usually the result of an inflammatory process, but they may be observed in other structures. The adhesions vary con- siderably in extent, number, mode of arrange- ment, firmness, and other characters ; they may merely consist of a few loose, slender, and deli- cate bands, or these bands may be thick and strong, or , the contiguous surfaces may be blended and matted together to a, greater or less extent, so that they, cannot be separated without tea.ring. or cutting them asunder, this last condi- tion constituting aggluiimaiion. In structure adhesions consist mainly of connective or fibrous tissue, more or less perfectly developed, with a few new vessels. Effects. — Adhesions are often found at post- mortem examinations, which have been of little or no consequence during life, as, for instance, many of thosewhich form in connection with the pleural surfaces. If, however, they are extensive and firm, or if they occupy certain regions of the body, they may prove of serious moment. The principal evils which are liable to result from adhesions may be thus indicated : — 1. They often, bind parts together, and interfere with the movements of important organs, such as the lungs, heart, stomach, or intestines ; in this way preventing the due performance of their functions. 2. When an organ is displaced in any way, as, for example,: the heart by pleuritic effusion, it may become fixed in its new position by the formation of adhesions, its functions being thus disturbed... 3. It is highly probable that agglutination may lead to hypertrophy of an organ, e.g., the heart, by embarrassing its move- ments, and. hence affecting its action. 4. On the other hand, atrophy or degeneration of structure may, ensue, in consequence, of the adhesions in- terfering with the due supply of blood by pressing upon the vessels, so that the nutrition of the tissues becomes impaired. In the yonng, also, 16 ADHESIONS. the development of stractures may be checked. 5. Adhesions may jnvolTe important structures, such as nerves or ve'ssels, pressing upon or de- stroying them, thus giving rise to symptoms of a serious nature. 6. Tubes or canals for the pas- sage of secretions or other materials are some- times narrowed or obliterated by adhesions. 7. When formed within the abdominal cavity, espe- cially when they take the form of bands, adhe- sions may prove highly dangerous by com- pressing, constricting, exerting traction upon, or strangulating some portion of the intestine, in either of these ways leading to intestinal ob- struction. It is frequently difficult or impossible to deter- mine the existence of adhesions by clinical inves- tigation during life ; but the history of some past illness during which they were likely to be formed, the results of physical esamina,tion, espe- cially in connection with the heart and lungs, and the symptoms present, not uncommonly enable them to be discovered. Feedeeick T. Eobbrts. ADIFOCSKXi {cideps, fat, and c«ra, wax). — Stwon. : Pr. Adipocire ; Ger. Fettwachs. DEFnrmoN. — ^A substance formed by a spon- taneous change in the dead tissues of animals. Desceiption. — As seen generally in a dried state in museums, adipocere somewhat resembles spermaceti in consistence, but it is less crystalline in fracture, and is of a dull white or bufif colour, the surface being marked by the outlines of blood- vessels or other textures. Adipocere in the earlier stages of its formation, or when formed in a damp situation, is soft, and if rubbed between the fingers communicates a greasy feeling. The odour is peculiar and rather disagreeable. Chemioai. Composition.— Adipocere dissolves in ether, leaving a delicate filamentous web ; it burns with a blue flame, yielding a ■white ash; It is properly described as a soap composed of mar- garic and oleic acids in combination with' ammo- nia, the fixed alkalies, and alkaline earths ; the relative proportion of the latter ingredients vary- ing with the age of the specimen (the ammonia disappearing), and with the composition of the fluids in contact with which the adipocere had been formed. It is said that oleic acid predo- minates in adipocere formed from dead fish. Microscopic Appeaeances. — ^Whentbe flesh of animals in vrhich this transformation has recently commenced is examined wdth the microscope; it is found to be composed of broken-down or dis- integrated tissues, fatty, granules or particles, together with a few acicular scales or crystals. The granules may be seen in what was muscular tissue to assume somewhat the arrangement of the muscular filaments, thus presenting an ap- pearance resembling an early stage of fatty degeneration. In old and dry specimens of adipocere the crystalline scales form the great portion of the mass, and they may be observed preserving the outlines of the muscular fibres. Oeiqin. — Adipocere has long been known. It is formed readily from the flesh of animals ex- posed to moisture, or placed in running water, in very dilute nitric acid, or in alcohol and water in the proportion of 1 to 6. It is often met with in inconvenient abundance in the ADIPOOEEK specimen jars of the anatomist. The bodies of men and other animals buried in peat moss have frequently been found completely converted into adipocere. Lord Bacon mentions it in the Sytva Sylvarum, and so also does Sir Thomas Brown in the HydriotapMa ; but attention was es- pecially called to its presence when a vast number of bodies were removed' (in 1786-87) from the Cimeiiere des Innocents at Peiris to the Cata- combs. Fourcroy found many of those bodies converted into what he named adipoeire, a name since retained. Gibbes (as did others) suggested the possibility of applying adipocere formed from the waste flesh of animals to some useful pur- poses, but the tenacity of the disagreeable odour andthepresenceof other difficulties haveprevented these suggestions from being carried out. 'With re- spect to the immediate changes which give origin to adipocere chemists have diflFered in opinion. One class believes with Gay-Lussac and Berzelius that the compound results from the fat originally present in the tissues, and that the other compo- nents are completely destroyed by putrefaction. The other class, which includes the names of Thomas Thomson and Brande, maintains ' that the fatty matter is an actual product of the decay, and not merely an educt or residue.' These opinions may, the present writer thinks, be reconciled by the better knowledge we now possess of the elementary composition of tissues. We know that the combination of fat and albu- min constituting one of the earliest steps in the process of nutrition is traceable in the further de- velopment and formation of nearly every texture. 'When that combination is destroyed by a ces- sation of the process of life, the tissues are as it were resolved into their primary elements. We may thus have adipocere derived not only from free fat, but from the elements of fat existingin and obtained from the decomposition of other tissues. Adipocere may thus be described as both an educt and a product. This opinion is confirmed by the researches of Bauer and 'Voit, who showed that fatty matter was derived from the meta- morphosis of albumin in starved animals, to which phosphorus had been administered.' The interest concerning this substance is not confined to the chemist. The medical jurist has studied it with the view of determining the time and progress of its formation, and of thus ascer- taining the probable period at which death oc- curred. But hitherto no decided or satisfactory information has been obtained, owing to' the varied circumstances which influence the progress of the change, in connexion not only with the condition of the body itself, but also with the character of its surroundings. The formation of adipocere has a further and a special interest for the pathologist. It was the study of this process which led the present writer to point out the analogy which exists between it and fatty degeneration in the living body, and thus to es- tablish the pathological doctrine that fatty dege- neration is the result of a retrograde metamor- ' The writer would desire to refer hero to the analogv which seems to exist between the change of animal matter into adipocere, and that which occurs in vegetable matter by its conversion into peat and coal. This, h ow- ever, is not the place in which to examine further suoh an analogy. ADIPOCEEE. phosis, due to defective nutrition. (See Medical and Chirurgical IWintactions, vo\. xxxiii.) SiCBABD QUAIK, M.D, ADIPOSIS. — A. term -which properly signi- fies eiihor general corpulency, or accumulation of adipose tissue in or upon an organ. See ]?ATTr Growth ; and Obesity. power). — Terms indicating serious depression of the vital powers, and employed as synonymous with the ' typhoid condition' The adjective is applied to diseases in which the phenomena of this condition are prominent. See Typhoid Condition. .aiGOPHONY (atj, a goat, and ^cov)), voice). — A peculiar alteration of the resonance of the voice, as heard on auscultation of the chest, compared to the bleating of a goat. See Physical Examination. iBTIOLOOY (ahta, cause, and \6yos, word). — That branch of pathological science which deals with the causation of disease. See Bisbasb, Causes of. APFINITY. — This term is the designation of a property by which elementary and com- pound substances unite with one another and form new compounds. It is, therefore, a pro- perty with which chemists are principally con- cerned. But the ideas suggested to the chemist by the term affinity are also, though less explicitly, excited in the mind of the pathologist and of the therapeutist by certain classes of facts frequently falling under their observation. The pathologist, for instance, knows that saline or earthy matter is very prone to accumulate in the midst of degenerated tissue in the walls of an artery or of a cardiac valve, so as to give rise to a patch of ' calcification ' ; he knows that in a gouty patient urate of soda is most apt to accumu- late and form 'chalk stones ' in the tissues around affected Joints ; he knows that, however it may be administered, arsenic in poisonous doses tends to produce inflammation of the alimentary canal, that strychnia acts with preference upon the ner- vous system, and that in ordinary cases of lead- poisoning this metal interferes especially with the nutrition of the extensor muscles of the forcr arm. Applications of the same notion in the department of therapeutics are equally familiar in respect to the action of many drugs. It may be rega.rded as an ascertained fact that iodide of potassium tends especially to influence the nutrition of the fibrous structures in the body, and that bromide of potassium has a nolesp certain action in modifying the nutrition of the nervous centres in many unhealthy states. Again, there is a whole class of substances which when taken into the system have, whatever their other actions may be, an undoubted effect in modifying the functional activity of the kidney. We have in nitrite of amyl a remedy possess- ing a remarkable influence over the unstriped muscular fibres of the arteries and bronchi, or else over the nerve-centres by, which they are controlled. We have in woorara an agent which acts especially upon the motor side of the ner- AGOBAPHOBIA. 17 TOQs system ; and we have in digitalis an im- portant remedy which, amidst its other pffects, •eoms to have a decided power of improving the nutrition of the cardiac ganglia. The recent progress of therapeutics encourages us to hope that more a'nd more of these specific effects of drugs will be accurately determined, so that the notion implied by the term affinity may, after n time, have a deeper meaning than at present for the practitioner of medicine. See Anta- aoNisM. H. Chablton Bastian. APFtrSION.— A method of treatment which consists in pouring a fluid, usually water, either cold or warm, upon the patient. See Water, Therapeutics of; and Baths. AFBICA, South.— See Appendix. AGEUSTIA (4, priv., and ytvats, taste), — IiOss of taste. See Taste, Disorders of. AGONY {irfbiv, strife or struggle). — Agony implies bodily pain or mental suffering so in- tense that it cannot be endured, but excites a struggle against it. It is also applied to the flnal struggle that often precedes death. See Death, Modes of. AOOBAPHOBIA {ir/opii, a market-place, and 0(i|3as, fear). Synon,: Fr. Lafeurdeiespaee*. — By these names a peculiar nervous complaint has been recognised, characterised by a feeling of alarm and terror, accompanied with a group of nervous symptoms, which some individuals experience when they are in a certain space. The condition may be developed rapidly or gra- dually, and the chief phenomena observed are as follows : — A sudden sensation is experienced, as if the heart were being grasped, while this organ palpitates violently; the face becomes flushed f the legs feel weak, tremble, and seem as if they would give way under the body. There may be sensations of itching, coldness, or numb- ness ; or profiise sweating may occur. There is no true vertigo ; the special senses are unaffected ; and consciousness is not at all impaired. A curious impression is sometimes experienced, as if space were elongating itself out indefinitely. Persons who are thus affected are quite sensible of the foolishness of their fear, but cannot be reasoned out of it. During the attacks they feel a strong inclination to cry out, but fear to do so. They think that their dread is known to others, and many of them endeavour to con- ceal their feelings, lest they should be considered insane. The circumstances under which the symptoms just described may be experienced are various. They may be felt, foi: instance, in the street, especially if the shops are shut ; in pubUe buildings, such as churches, concert-rooms, or theatres ; in omnibuses, cabs, or other convey- ances ; on a bridge ; or in looking at an extended facade or flying perspective. Most persons who suffer thus in the street feel better when with some one, or when near some object, such as a carriage, or even when carrying an umbrella op a stick. Occasionally, however, they shun other people, especially acquaintances. But little is known as to the origin and nature of agoraphobia. The complaint is not regarded 18 AGOEAPHOBIA. aa idiopathic, but as sequential to some other condition. It occurs in males and females, and the individuals affected may be strong and in good bodily health, while they are often intel- ligent and TTell-edncated. A history of heredi- tary nervous disorder can be traced in some cases, indicated by the occurrence of insanity or epilepsy in members of the family ; and the patients themselTes may present indications of a nerrous temperament. Their emotions may be easily excited; and they may be subject to nervous symptoms, such as headache, a feeling of heat in the top of the head, sparks before the eyes, occasional faintuess, or motor disorders. Fbgdebick T. Bobebts. AQBAFHIA. ! Aphasu.^ AGBIA {Srypios, wild). — This term signifies angry aud severe. Willan describes a Lichen offHus, which is likewise termed Agria ; it is a circumscribed inflammatory eczema situated on the back of the hands. The qualities implied by agria are excessive pruritus, burning pain, thickening, fission, and copious exudation. EeASMUS WlLSOlf. AQTTB. — A popular synonym for Intermittent Fever. See Intbbmitxeikt Fever. AGTIB-CAKE. — ^A form of enlargement of tKe spleen, resulting from the action of malaria on the system. See Sfleek, Diseases of ; and Maiabia. AIB, uSitiology of. See Disease, Causes of. AIB, Therapeutics of. — Air is employed in the treatment of disease in many ways and for many purposes. It is used, first,' as the atmosphere, a gaseous mixture of definite compo- sition and with a variable pressure. Secondly, advantage is taken of air as a vehicle for other substances in the gaseous or finely divided state. And, thirdly, it is selected as a medium by which the temjpereutwre of the bodymay be readily and effectively influenced. In the first of these relations only — as pure air — will its therapeutics require to be considered in this article. The application to the body generally of air that has been warmed, or warmed and loaded with mois- ture, will be found described in the article on Baths; while its administration to the respi- ratory organs, either in this form or as a vehicle for such substances as creasote, carbolic acid, alkaloids, and sulphurous acid, will be dis- cussed under Inhalations. Principles. — ^The dual relation in which the air stands to the economy — as a definite compound of certain gases, and as an atmosphere with a certain pressure — is very frequently disturbed; and this disturbance accounts for some of the most familiar phenomena of disease. Alteration in the quality or quantity of the respired air, w'hether from the state of the atmosphere itself or from derangement of the complex apparatus of respiration and circulation, is the cause of some of the most serious and distressing symp- toms attending diseases of the chest. It might be predicted by the physiologist that under these circumstances relief would be afforded, at least to symptoms, by suitable alteration of the com- pdsition or volume of the air. The method of AIE, THERAPEUTICS OF. treatment thus rationally indicated is further readily practicable — ^the supply of air is un- limited ; its composition may be altered at plea- sure; its pressure may be increased or dimi- nished ; and such alteration will alter its chemical properties. We find accordingly tliat, ever since the discovery of the composition of the atmo- sphere, frequent trials have been made of its value therapeutically. Oxygen was early recog- nised as its active constituent, and came to be administered, as it still is, in the form of inhalation. From time immemorial, indeed, advantage has been taken of the purity and certain other unknown qualities of the air for the prevention and treatment of disease ; and the character of the atmosphere is natur- ally reckoned one of the most important ele- ments of climate (see Climate). More recently use has been made of the powerful properties that air possesses when physically changed. Within the last few years a remarkable advance has been made, on the one hand, in the physio- logy of respiration and the relation of the circula- tion to the atmospheric pressure, and, on the other, in the pathology of diseases of the chest. Clearer views have been reached on the signifi- cation of various symptoms, and especiafiy of ■ dyspnoea in its different forms. At the same time observations upon the effects of compressed a.nd rarefied air have been becoming more exact. Pursuing the physiological trade, modem the rapentists have availed themselves of this know- ledge, and revived the use of air physically altered in the treatment of diseases of the longs, heart, and other parts of the body. This ap- plication they are now able to mate with accu- racy, and the success of the reformed system of aerotherapeutics appears to be unquestionable. Although in England it is seldom heard of beyond hydropathic establishments, the system is more extensively employed on the Continent. Its leading principles and some of its most important applications will be here briefly de- scribed. The physiological effects of compressed or of rarefied air will manifestly be different accord- ing as it is admitted to the body as a whole, or only to a part of it. Familiar examples of the former condition are afforded by descent in the diving- bell, or ascent in the balloon ; and of the latter by the action of the cupping-glass, and the effect of interrupted or frequently repeated respirations upon the pulse and system generally. Under the first circumstances the alteration of pressure is absolute; under the second it is relative, and capable of producing most important disturbances in the distribution of the vital fluids. The two methods of application must accordingly be separately discussed. General Aerotherapeutics. — The effects of compressed air on the body as a whole have been studied in the air-bath, a simple mechanical arrangement in the form of an iron chamber, which can be filled with air at any pressure, whether above or below the normal, by Jneaiis of steam-power. The principal physiological effects of air condensed by three-sevenths of an atmosphere were ascertained by von Vivecot to be: — Pallor of the skin aud mucous mem- branes; a sensation of pressure in the oars; AIB, THEEAPEUTICS OF. le diminished frequency of respiration, the act be- coming easier; enlargement of the lungs, and increase of the vital capacity ; depression of the cardiac force, and diminution of the size and strength of the pulse; rise of temperature ; in- creased Tigour of muscular action, secretion, and nutrition generally ; compression of the gaseous contents of the intestines j and, perhaps,- inr creased absorption of oxygen and excretion of carbonic acid. When the pressure is excessive, dangerous or even fatal symptoms may super- vene. Frequent exposure to condensed air will mduee conaderable increase of the vitalcapacity ; and most of the other effects, both physical and chemical, will tend to persist. In a word, it may probably be said that the air-bath acts on the system, first, by increasing the general me- chanical pressure; and secondly, by admitting an increased amount of oxygen. In employing the air-bath, the patient is kept in it for a period of two hours, , at first daily, but after some weeks less frequently. The pressure, which !s employed in different cases at one-fifth to 3ne-half of an atmosphere above the normal, most be slowly raised onadmission,>Tn^toms are jjhiefly important in the case of the Uvcr, spleen, and kidneys. Uniform smooth ALBUMINS. 21 enlargement of the liver and spleen, which can be referred to no other cause, may be due to the albuminoid change. Where the kidney is affected, albuminuria, dropsy, urajmia, and a train of symptoms arise, which, regarded as a whole, differ from those of other kidney diseases. The dia/jnnaia is greatly confirmed by (1) the simultaneous occurrence of disease in several organs ; (2) a history of suppuration, or of some cachectic disease, especially syphilis. The prognosis is extreniely unfavourable, and, when the disease is far advanced, it is hopeless. Tbeatmbnt. — Though in advanced cases treat- ment can avail but little, there is reason to think that were the occurrence of disease anticipated, or its presence earlier recognised, prevention, or even cure, might be possible. In all such com- plaints as chronic joint-disease, psoas abscess, sy- philitic disease of bone, or prolonged empyemaj the probability of this frequently fatal gejue^a should be borne in mind, and guarded against by a suit- able regimen. The diet should not only be gene- rally nutritious, but should include more especially abundance of nitrogenous food (albuminates), as well as the potassium salts^ which the affected tissues lack. These are, indeed, largely contained in the juices of fresh meat, and also in the green parts of vegetables. Among drugs, nutrient tonics, of which iron and cod-liver oil are the type, must hold the first place ; but the adminis- tration of potassium salts, as proposed by Dr. Dickinson,.iB also indicated. Of these we should be induced, on a priori grounds, to select those of which the local action is least violent, and which cause little vascular depression, such as the bicarbonate, or the citrate, or other organic salts. The danger of ' potash poisoning ' is very remote. J. E. Payne. AIiBtJMIIfS.^ — Definition. — Albiimins are substances closely resembling egg-albumin, the chief constituent of white of egg or albu- men. To distinguish between the white of egg and its chief constituent, the former is spelt albumen and the latfer albumin. Albumins constitute a sub-division of the class of albu- minous bodies, which includes all subsbmces having a general resemblance to albumen. Entjmbbation. — The sub-class properly con- tains only two members, egg-albwmin and serum- all)U9tiin ; bi^t the name £ence- Jones's albumin has been given to an albuminous body differing very considerably in its properties from the other two. Chaeactees. — Egg-albumin and serum-albu- min are semi-transparent, yellowish, and struc- tureless when dried. They ara soluble in water ; and,this solution is coagulated by boiling. ,From the same solution they are precipitated by (a) nitric acid; (6) salts of the heavy metals, for example, copper-sulphate ; (c) acetic acid with potassium-ferrocyanide ;. (d) boiling with acetic acid and a neutral salt, for example, potassium- sulphate; (e) alcohol. EggTa.lbumin is distin- guished from, serum-albumin by the coagulum which it forma with nitric acid being insoluble in excess, whilethatof serum-albumin js soluble. Bence-Jones's albumin gives no precipitate with excess of nitric acid unless left to stand, or un- less heat«d and left to cool, when jt forms a solid 22 ALBUMINS. coagulum. This coagulum redissolves on heat- ing, and again forms on cooling. It may bo separated from ordinary albumin by adding nitric acid, boiling, and filtering when hot. The ordinary albumin will remain on the filter while Bence-Jones's albumin will pass through, and will coagulate when the filtrate cools. MoDiFicATioifS. — By the action of acids and alkalis albumin may be converted into add-albit- mm and alkali-albumin respectively, neither of which is coagulated by boiling. Acid-albumin may be formed in two ways ; — T'irst, by dissolring solid albumin in concentrated nitric or other mineral acid with the aid of heat. Secondly, by heating an aqueous solution of albumin with one of these acids very much dilated (1 in 500). Although soluble in very concentrated or very dilute acids, acid-albumin is insoluble in moderately dilute acids. There- fore, when the solution in concentrated nitric acid is diluted with water, a precipitate is formed, which redissolves when much water is added. Aud, conversely, when acid-albumin is made by boiling a solution of albumin in water with very dilute nitric acid, the addition of more acid will throw down a precipitate, which redis- solves if a very large excess of the concentrated acid be added, and especially if it be heated at the same time. On neutralizing a solution of acid-albumin, a precipitate is thrown down, which dissolves in excess of alkali. AlkaU-albumin, or Alkali-albuminate as it is also called, is formed by dissolving albumin in caustic potash or soda ; or by adding either of these to its aqueous solution and allowing this to stand, or heating it. This modification is not precipitated by heat, but is precipitated by neu- tralization; the precipitate dissolving very readily in slight excess of acid. If alkaline phosphates are present in the solution, as theyare in urine, alkali-albumin requires n, slight excess of acid to throw it down, and is not precipitated by exact neutralization, as acid-albumin would be under similar circumstances^ T. Laudee Beunton. AIiBTTMIKTITBIA. — Definition. — A condi- tion characterised by the presence of albumin in the urine. Other albuminous bodies, not albu- mins, may be present in hsematinuria, hsema- turia, pyuria, and spermatorrhoea. Symptoms. — ^Albumin may occur in the urine without any symptoms whatever, but its con- tinuous loss leads to anaemia and changes in the circulation, which usually originate the following symptoms— a pallid pasty complexion, dry skin, and tendency to oedema of the cellular tissue noticeable on the eyelids and shins ; derange- ment of digestion, flatulence, occasional nausea, and irregularity of the bowels ; nervous disorder shown by muscular weakness, languor, lassitude, vague pains about the loins, and headache ; calls to make water during the night ; palpi- tation, and frequently accentuation of the second sound of the heart over the aortic cartilage, and reduplication of the first sound over the septum ventriculorum. Tests fob Albumin. — The two tests usually employed to detect albumin in the urine are — first, boiling ; and, secondly, the addition of nitric acid ; both of which produce a cloud or precipi- ALBUMINUEIA. tate. If the urine is turbid the albuminons cloud may not be noticed ; and therefore such urine should be filtered before the application of either test, unless the turbidity, being depen- dent on the presence of urates, is removed by heat. Method of employing the test by boiling. — With the object of saving time the urine is often boiled at once, but the results thus obtained are liable to several fallacies, which will be subse- quently described. In order to avoid such fallacies the following method should be pursued : — Ascer- tain the reaction of the urine ; and, if it be alkaline or very strongly acid, add acetic acid in the one case, or liquor potassae in the other, until its reaction is only slightly acid. Fill a test-tube to about one-third of its capacity with the urine, and hold it obliquely in the flame of a spirit lamp in such a manner as to heat the upper part of the fluid only, until it boils. If it be turbid from urates, it should be first warmed throughout until it becomes clear, and then the upper part only should be boiled. Finally, add a drop or two of acetic or nitric acid. If albumin be present, it will form a cloud or a coagulum, more or less dense according to its amount. When there is much albumin, its quan- tity may be roughly estimated by allowing the urine to stand for a definite number of hours, so that the coagulum may subside, and then observing whether it forms a fourth, a third, or a half of the whole length of urine in the test- tube. A small quantity causes a cloud, but no distinct coagulum ; and, if merely a trace be pre- sent, a faint haze only will be observed, which is best seen by looking through the test-tube at a dark object. The- advantage of heating the upper part only of the urine is, that the lower portion, which remains clear, affords a standard by comparison with which a faint cloud in the heated part may be more readily detected. Fallacies of the test by boiling, — The first fallacy is that albumin may be present, and yet no cloud or coagulum be produced on boiling. This may occur if the urine be alkaline or very strongly acid, because alkali-albumin or acid- albumin, which are soluble in water, may be formed. It is to prevent the formation of alkali-albumin that acetic or nitric acid should be added to alkaline urine before boiling. This addition of acid also causes the coagulum to separate more readily ; and it should therefore be made when the urine is neutral. On the other hand, urine rarely or never contains sufficient acid to form acid-albumin, unless the patient has been taking mineral acids ; and therefore th» addition of liquor potassae is not necessary except, under these circumstances. The second fallacy of the test by boiling is, that a cloud resembling that of albumin may be produced, although the urine is free from this substance. This occurs when the acidity of the urine is too slight to hold the earthy phosphates in solution, without the aid of the carbonic acid which it usually contains. "When such urine is boiled, the car- bonic acid is driven off, and the phosphates are precipitated, forming a cloud like that of albumin. The two clouds are readily distinguished by the addition of a drop or two of nitric or acetic acid, when if due to phosphates it will disappear ALBUMINURIA. 23 by solution ; but if caused by albumin it ■will remain. If an exeessivo quantity of nitric acid be added, an albuminous cloud may also clear up ; for albumin coagulated by heat is soluble iu strong acid, though only to a slighfextent. Application of the nitrie-aoid test. — Pour some urine into a test-tube, and then allov about one-fourth of its bulk of strong colourless nitric acid to trickle slowly down the side of the tube, so as to form a lay er below the urine without mixing. Or the acid may be put in the test-tube first, and the urine poured on it. Both processes give the same result. If albumin be present, a haze or cloud will form close to the line where the liquids meet. Fdllaoies of the nitric-acid teat. — 1. Albumin may be present and yet escape detection, if the nitric acid is simply poured into the urine and mixed with it, as is sometimes done. For if there be too much or too little acid, acid-albumin is formed and dissolved ; whereas, if the liquids form two distinct layers, as in the process already described, the acid gradually mixes with and shades off into the urine, so that, at a greater or less distance from the line where they join, it is certain to be of the proper strength to precipitate the albumin. 2. Albuminmay be supposed to be present when it is not, from the formation of a cloud by the precipitation of acid urates or uric acid. This cloud disappears on the applica- tion of heat : and another specimen of the urine tested by boiling gives no cloud. To avoid this fallacy, it is common to employ the test by boiling, in addition to that by nitric acid. 3. The third fallacy is not of common occur- rence. It is due to the presence of fat or saponi- fied fats in the urine. Urine containing these when simply boiled gives no cloud ; but if nitric acid is added to it in the cold, or acetic acid when it is hot, the fatty acids are precipitated and form a cloud resembling albumin. This is distinguished by not being formed if along with dilute acetic acid some ether is added to the urine before boiling; the ether retaining the fatty acids in solution. If the precipitate pro- duced by nitjic acid be collected on a filter, and treated with ether, it will be dissolved, while an albuminous precipitate will not. Copaiba, which can be recognised by its smell, sometimes causes an opalescence in the urine, which is increased by nitric acid, but is removed by heat. Additional tests for albumin. — When urine contains mucus, which would render the presence of an albuminous cloud obscure, a solution of ferroeyanide of potassium followed by acetic acid should be added : this will produce a cloud if albumin be present, while it rather dears up a tur- bidity due to mucus. A solution of pyrophosphate of soda also precipitates albumin. If a drop of albuminous urine be poured into a test-tube containing one or two drachms of a saturated solution of picric acid, a precipitate is formed. These tests are sometimes useful in determining the presence of albumin in the urine in doubtful cases. QuANTiTATiVB ESTIMATION OF Albumik. — There '' are three methods in common use for this pur- pose. The first is easy but inexact. It consists m boiling the urine with dilute acetic acid in a test-tube, allowing the coagulum to subside for a definite number of hours, and then estimating the proportion it bears to the quantity of urine boiled, for example, a fourth, a third, &c. The second is the most exact, but is troublesome. It is like the first ; but the urine is carefully measured before boiling, and the amount of coagulum is ascertained by collecting It on a weighed filter, washing, drying, and again weigh- ing it. The third method is easy and tolerably exact. A tube of known length is filled with urine and placed in a polarizing apparatus. From the amount of rotation which the polarized ray undergoes in passing through the urine, the amount of albumin it contains may be calcu- ated. A fourth method has recently been re- commended by Dr. W. Roberts. It consists in diluting the urine with water until it gives a haze on the addition of nitric acid, which does not become visible until between one-half and three-quarters of a minute after the acid has been added. This dilute urine contains 0'0034 per cent., or O'OllS grain of albumin per fluid ounce ; and from the degree of dilution required the amount contained in the urine may be calculated. Patholoqt. — Albuminuria has been said to occur in consequence of various conditions : e.g., changes in the blood, changes in the circulation, changes in the kidneys. Thus abstinence from salt, or a diet of eggs alone, is said to product albuminuria by altering the constitution of the blood ; and an alteration in this fluid is sup posed to be partly the cause of the albuminuriu observed in high fevers, scarlatina, diphtheria, and osteo-malacia. The albuminuria of heart- disease depends on changes in the circulation, and that of nephritis on alterations in the kidney. In order to distinguish more clearly between the different kinds of albuminuria we may divide them into — 1st, true albuminuria, in which serum- albumin appears in the urine ; 2ndly,/a^«e albu- minuria, in which some other albuminous body, but not serum-albumin, is present. In true albuminuria there is always some change either in the circulation through the kidney, or in the structure of the kidney itself. In false albumi- nuria the albuminous body passes out through the kidney, without there being any alteration either in its circulation or structure. The chief albuminous bodies occurring in false albuminuria are haemoglobin, egg-albumin, and Bence-Jones's albumin. Haemoglobin occurs in the urine whenever blood is present in it (see Htematteia), in which case it is contained in the corpuscles ; or it may occur free {see Hjema- tinuria), the blood-corpuscles, while still circu- lating in thevessels, having undergone solution. This may result from the inhalation of arse- niuretted hydrogen, or from the introduction of bile-acids or of a large quantity of water into the veins. Hsemoglobin is also found in the urine in paroxysmal hsematinuria, but the cause of the solution of blood-corpuscles in this disease is unknown. Egg-albumin is excreted by the kidneys, and appears in the urine, whenever it is injected directly into the circulation or under the skin, or when it is absorbed unchanged from the stomach or rectnm. When taken into the sto- mach it is usually completely digested before it undergoes absorption ; but when taken in such u ALBUMINUEIA. Utgo quantities that the whole of it cannot be digeBled, part of it is absorbed unchanged and is excreted in the urine. Thus a diet consisting exclusively of eggs, especially when continued for several days, produces false albuminuria, and large enemata of eggs have a similar effect in animals and probably also in man. Bence-Jones's albumin is of very rare occurrence. It is found in osteo-malacia. Like egg-albumin, it is ex- creted by the kidneys when it is injected into the circulation or in large quantities into the intestine. It is almost if not quite identical with the hemialbumose, which Kuhne finds to be one of the products of imperfect digestion. It seems probable that those cases of albuminuria which appear to depend on imperfect digestion are due to the passage into the systemic circulation of albuminous bodies, which have not undergone the proper transformation in the alimentary canal or liver. * In true albuminuria there must be some change, either in the circulation or structure of the kidney, for serum-albumin differs from the other albuminous bodies just mentioned, in not being excreted by the healthy kidney. Some re- gard the alterations in circulation which produce albuminuria as of two kinds : — (a) increased pres- sure of blood in the renal arteries; (i) increased pressure in the renal veins. Increased pressure in the arteries may depend either on general high arterial tension, or upon an increased local supply of blood to the kidney, owing to dilatation of the renal arteries, such as follows division of their vaso-motor nerves. Experiments seem to show, however, that increased tension in the renal arteries does not produce albuminuria, and that the only change in circulation which will cause it is increased pressure in the renal veins. Con- gestion of the renal veins may be produced by ligature of the renal arteries, and when the flow of blood through the kidney is temporarily arrested by ligature of the artery, the urine secreted after the removal of the ligature is albuminous. Venous congestion of the kidney also occurs whenever the onward flow of venous blood is obstructed, either by a ligature on the renal veins ; by the pressure of a. tumour or of tho pregnant uterus upon them or the vena cava ; by disease of the liver obstructing the vena cava; or by disease of the heart or lungs, such as tricus- pid or mitral regurgitation, or chronic bronchitis and emphysema. The temporary albuminuria sometimes observed after cold bathing may also be due to venous congestion ; and it is probable that albuminuria consequent upon lesions of the nervous system is due rather to the changes which these produce in the circulation than to any direct action of the nerves upon the tissues of the kidney itself. The albuminuria observed after varnishing the sidn is probably due to the retention of some substance which acts as a, poison. The structural changes in the kidney which cause albuminuria are acute and chronic inflammation, waxy degeneration, and cirrhosis. See Bkight's Disease. Treatment. — In false albuminuria where hae- moglobin appears in the urine, the treatment in- dicated is to counteract the solution of blood-cor- puscles; and for this purpose quinine is very often useAil. When other kinds of albumin ap- ALCOHOL. pear in the urine, and are probably due to ini- perfect digestion, the treatment is to give soma artificial digestive fluid. Arsenic is also usofiiL Eegarding those cases of osteo-malacia in which Bence-Jones's albumin occurs, we unfortunately know very little. In true albuminuria, depending on venous congestion, the obstacle to free circulation should be removed, if possible; and conges- tion lessened, both by drawing the blood from the interior to the surface of the body, and by causing contraction of the renal vessels. The blood may be drawn from the interior to the surface by means of warm baths, but in some cases tliey prove injurious rather than useful, and the employment of a wet pack, which has a similar effect on the distribution of blood without exciting the heart, is to be preferred. Cupping over the kidneys is serviceable : it pro- bablyacts by causing reflex contraction of the renal vessels rather than by actually draining blood away from them. The tone of the renal vessels may be increased by the employment of digitalis (see DrnEKTics) ; and this drug is useful even when no cardiac disease is present, although its good effects are still more marked when the con- gestion is dependent on disease of the heart. The constant drain of albumin from the body occa- sions anaemia, which not only produces many unpleasant symptoms, but tends to cause fatty degeneration of various organs, from which there is no reason to believe that the kidneys are exempt. The administration o£ iron, therefore, is the chief remedy in structural disease of the kidneys, and it is useful by diminishing or re- moving the symptoms of anaemia and the ten- dency to fatty degeneration consequent thereon, and also by increasing the tone of the vessels, thus diminishing the loss of albumin. T. Laxtdeb Bbunton. AliCOHOL. Stnon. : Ethyl-Alcohol ; Vinie Alcohol ; Spirit of Wine (C^HoO). — Alcohol is the product of a process of fermentation induced by the action of a microscopic fungus, Yeast, upon certain kinds of sugar, especially grape sugar, but also upon that derived from starch 'of any description, and, in the same manner, upon milk sugar. In this process a peculiar meta- morphosis takes place, by which alcohol and car- bonic acid are produced in considerable amount, together with very minute quantities of succinic acid, glycerine, and other bodies. Alcohol may also be produced synthetically from its elements, carbon, hydrogen, and oxygen. As alcohol is very volatile, boiling at 172° Fahr. (78° C), it may readily be separated by distillation from the watflr with which it is at first combined.. Other means must be resorted to, however, in order to separate the very ulti- mate particles of this water, as a strong attrac- tion exists between the two liquids. Alcohol, diluted with about 95 per cent, of water, and subjected to the action of another microscopic fungus, is oxidised into aldehyd and acetic acid. PHrsioLOGioAi. EprECTS. — Applied to th« skin, alcohol produces a sensation of coolness, due to its rapid evaporation ; but, if the appli- cation be continued sufficiently long, irritation ALCOHOL. 25 is excited. This latter effect ensues imme- diately if alcohol ia brought into contact with a mucous membrane. Its stiong attraction for water seems to be the chief cause of this action. Alcohol is a powerful an<»sep<»e, probably from the fact that it is capable, even when diluted, of preventing the development of septic germs, such as vibrios and bacteria, as well as of paralysing the activity of those already formed. There ia scarcely any other therapeutical agent the internal action of which varies so much ac- cording to the dose given. In tmall quantity, and slightly diluted with water, alcohol promotes the functional activity oif the stomach, the heart, and the brain ; whilst a like quantity, largely diluted, exerts but a limited influence upon these organs : if, however, the dose of alcohol be often repeated, it is readily assimilated ; and, becoming difiused throughout the system, undergoes com- bustion within the tissues of the body, imparts warmth to them, and yields vital force for the performance of their various functions. Simul- taneously with this consumption of alcohol, the body of the consumer is often observed to gain in fat — a circumstance due to simple accumulation, the &t furnished by the food remaining unburned in the tissues, because the more combustible alcohol furnishes the warmth required, ISaying no necessity for the adipose hydrocarbon to be used for that purpose. A quantity of 100 cubic centimetres of alcohol per diem (about three and a-half fluid ounces) — equivalent to abontone litre of Ehine wine of medium strength — is sufBcient to supply between one-third and one-quarter the whole amount of warmth requisite for the human body during the twenty-four hours. The warmth so supplied cannot be measured by a thermometer, however, any more than can that furnished by the internal combustion of other hydrocarbons, such as the oils or sugars. The subjective im- pression of increased warmth usually experienced after taking a dose of any alcoholic liquid is deceptive, and is only due to an irritation of the nerves of the stomach, and to the increased cir- culation of blood through the cutaneous vessels, particularly those of the head. Doses somewhat larger, but still sufficiently moderate not to cause intoxication, act, for the most part, in the same wily ; but, as an additional effect, they produce a distinct decrease of tem- perature in the blood, lasting half-aU-hour or more. As far as the matter has hitherto been ex- plained, this latter effectdepends upon a directly depressing influence exerted by alcohol upon the working cells of the body, and upon a temporary paralysis of the vaso-motor nerves. The latter is followed, of course, by dilatation of the super- ficial vessels, particularly those of the bead, in consequence of which a larger surface of blood is exposed, and the loss of heat by irradiation into the air is increased, the temperature of the circulating fluJd being thus lowered ; whilst, the combiistion Carried on by the cells being; re- tardedj the guceration of heat from this source is diminisiied. The quantity of carbonic acid eliminated is thus diminished, as is also the amount of urea excreted. After the organism has become inured to the action of alcohol, these effects upon the temperature of' the blood are less distinctly, or not at all, marked. The agreeable excitement at first cauaed by such doses of alcohol is succeeded by a reaction, characterised by lassitude and drowsiness, the latter condition usually lasting longer than ths previous one of exhilaration. The symptoms: of intoxication produced by larffe doses of alcohol are sufficiently well known. When the abnormal condition of excite- ment in the brain induced by this stimulant has been kept up, almost without intermission, for a length of time; or when it is suddenly withdrawn after the organ has been long subjected to it ; the disturbance brought about is so great and persistent as to result in a complete overthrow of the reas»ming faculties, and the condition known as delirium tremens ensues. At the same time that this pernicious influence is being exerted upon the cells of the brain, fatty accumulations may take place in other organs, particularly in the liver, heart, and connective tissues ; the blood-vessels become diseased ; and, in many instances, cirrhosis of the liver, kidneys, and meninges makes its appearance, as part of the general disorder of nutrition. The shrinking of connective tissue, characteristic of this last-mentioned complica- tion, seems to depend upon the direct irritation caused by the presence of un-oxidised alcohol. Under ordinary circumstances, and after the consumption of moderate quantities of alcohol, only slight traces of it are to be detected in the urine, and none whatever in the breath. Pure alcohol imparts no taint to the exhalations of the body; the ethers and fusel oils, on the other hand, do so by reason of their being less readily combustible. It is very likely that alcohol is completely oxidised into carbonic acid and water during the process of assimila- tion ; at least, no other secondary products resulting from its disintegration have as yet been detected. Thebapedtical AppLiciTioNs. — There can be no doubt but that a healthy organism, supplied with sufficient food, is i capable of 'performing aU its regular functions "without requiring any specially combustible material for the generation of heat and' the development of vital force. But the case assumes a different aspect when, in sickness, it transpires that, while the metamor- phosis of tissue goes on with its usual activity, or with increased energy, as happens in many diseases, the stomach, refusing to accept or digest ordinary food, fails to supply material to com- pensate for this waste. Here it is, then, that a material which can be most readily assimilated by the system, and which, by its superior com- bustibility, spares the sacrifice of animal tissue, is especially called for ; and such a material we have in alcohol. Small but oft-repeated doses of alcohol, largely diluted with water, are gene- rally well tolerated by the weakest stomach ; and, thus given, the absorption and,' oxidation of the spirit goes on without difficulty or effort on the part of the patient's system. According to . the, experiments of Dr. Frank- land and othersj the burning of I'O gramme of alcohol yields sufficient heat to raise the tem- perature of seven litres erf water 1°C. ; and the burning of 10 gramme of cod-liver oil suffice? for nine litres. Now, in taking three table- ALCOHOL. spoonfuls of the oil daily, we yield about the eame amount of warmth to the body as is given by four table-spdonfuls of absolute alcohol-^the quantity contained in a bottle of light claret or hock. The oil, however, is digested and oxidised by the organs of the body with difficulty, while, for the assimilation of the alcohol, scai-cely any exertion of the working cells is required. Thus, it can be demonstrated by calculation, as above- mentioned, that heat-producing material, suffi- cient to supply nearly one-third the whole amount of warmth required by the body within twenty-four hours, is offered in a quantity of 100 grammes (about three and a-hidf fluid ounces) of alcohol. In this sense alcohol is a food ; for we must regard as food not only the building material, but all substances which, by their combustion in its tissues, afford warmth to the animal organism, and, by so doing, con- tribute towards the production of vital force, and keep up the powers of endurance. Alcohol, therefore, diluted with at least 90 per cent, of water (in any convenient form of beverage), may be given with advantag'e, in small but oft-re- peated doses, in most of the acute and chronic diseases where it is desired to sustain the strength of the patient, but where at the same time the digestive organs, from any cause, refuse to tolerate a more substantial form of nourish- ment, at least in quantities that would answer the necessities of the case. In such cases it is certainly not sufficient to call alcohol merely a stimiilant. If alcohol served he*e only in the quality of a stimulant, its effect would soon pass away, leaving the patient more ex- hausted than ever ; for the human organism is BO constituted that it cannot be driven to per- form its functions by the application of mea- sures that simply stimulate, without supplying some new force to take the place of that put forth by the organs of the body under the im- pulse of excitement. To take a familiar illus- tration, alcohol thus given stimulates no more than does the -easily burning coal which we put in small quantities upon a languid fire, to pre- vent its going entirely out. Medium doses act powerfully upon the brain and heart, and are therefore serviceable as real stimulants in cases where it is desirable to excite the cerebral and circulatory systems to greater activity. We must not forget, however, that, while exciting this increased activity, such doses do not elevate the temperature of the body ; on the contrary, where the effect can be measured, it is found that they depress it a little. By con- tinuing to exhibit such doses, we can sometimes (in erysipelas, puerperal peritonitis, and similar diseases) lower febrile heat by alcohol where even quinine proves ineffectual. The consequences of this decline of fever-heat are an immediate re- storation to consciousness, if deliriumor stupor has been present ; and, in any case, a general improve- ment in the feelings of the patient. Todd and his school, before the application of the thermometer, called this the effect of stimnlus, while in reality the improvement is due almost entirely to the withdrawal or diminution of febrile disturbance. As fever patients can tolerate large quantities of alcohol without showing any sign of intoxica- tion, it is allowable, and sometimes even neces- sary, to rise in the scale of doses beyond the limits ordinarily prescribed. Of late years alcohol has been given during the night to hectic phthisical patients as a preventive against copious and exhausting at- tacks of sweating, and with a gratifying amount of success. Such patients certainly tolerate the remedy much better than has hitherto been generally supposed. It need hardly be said that, in cases of cardiac excitement, not resulting from fever, alcohol is at least to be used with caution. Mode op Administeatio». — One of the most important, but at the same time most difficult, points for decision is the exact nature and quality of the alcoholic drink to be prescribed or allowed to a patient, who may require alcohol in some form. Por general use, a pure Claret, Hock, or Mosel wide are the preparations most to be recommended. Cognac, Champagne, old Gin or Whisky, and the heavier Southern wines, may also be used according to circumstances. But whatever drink may be selected, it must at least be free from fusel oil to such an extent that a healthy man, even after imbibing a consider- able quantity, will not feel any other effects than those of a pure stimulus; that is to say, an agreeable exhilaration of spirits, neither accom- panied by a sense of weight in the head, nor followed by that persistent overfilling of the cerebral vessels and dulness of ideas charac- teristic of the physiological effects of fusel oil. The Fusel Oils (so-called from their oily quali- ties) consist chiefly of propyl, butyl, and amyl alcohol, of which the last-named forms the largest proportion. In order to examine any specimen of alcohol with reference to its purity from these objectionable constituents, it is only neces- sary to rub a few drops between the palms of the hands for half a minute, by which rapid evaporation is caused, and then to smell the moist spot left on either palm. If the alcohol be pure no odour whatever should remain, as ethyl alcohol evaporates very quickly; amyl alcohol, on the contrary, is much less volatile, and, if present in the liquid, will not have evaporated, so that its peculiar and unmistake- able odour will remain to attest its presence as an impurity in the specimen examined. This test is not applicable to the more com- plicated liqueurs and wines, as these all contain certain odoriferous organic principles of their own that might disguise the smell of the fiisel oil. The inoffensive quality of any given pre- paration, as a wine or spirit, can only be relied upon when one knows by experience that it is pure ; and then it should always be obtained, if possible, &om the same source, so as to ensure uniform purity. By far the most pernicious of all the ordinary drinks in use is the spirit obtained from potatoes, as this contains the largest proportion of fusel oil. Even after being redistilled, this liquor is still tainted with the poison to a fearful extent. Of course, wines mixed with such spirit possess the same objectionable qualities ; whilst wines made from must to which potato-sugar has been added are likewise tainted, though to a less degree. It can easily be demonstrated by experiments upon animals, that amyl alcohol is the agent to the presence of 'which the extremely poisonous ALCOHOL, action of many drinks upon our nerves and other organs is due. All distilled drinks made from other sources than from grapes contain it to & greater or less extent. To facilitate the process of estimating the quantity of any particular beverage necessary to be administered in order to produce a given effwt, ft table is subjoined sho-wing the per- centage of absolute alcohol contained in average specimens of the different kinds of wine, beer, &c, in common use. Absolute Jlcohol contained in — Kumisa (a fermented liquor made from whey) Is from 1 to 3 vol. per cent. German Boer * is from 3 to 6 vol. per cent. Hock or Cilaret is from 8 to 11 vol. per cent. Champagne is from 10 to 13 vol. per cent. Bonthern Wines (Port, Sherry, Madeira, to.) Is from 14 to 17 vol. per cent. Brandy and the stronger liqueurs is from 80 to SO voL per cent. For anti'pyretio purposes one will need to give an adult daily not less than the equivalent of fifty cubic centimetres (about two fluid ounces) of absolute alcohol, in divided doses within an hour or two. Taking this as a starting-point, the dose suitable for each individual ease can be estimated accordingly. The great quantity of carbonic acid contained in certain ' sparkling ' wines acts upon the tem- perature of a fever patient much in the same favourable manner as the alcohol itself, and when alcohol is to be taken as a food, it would seem that the impregnation with carbonic acid facilitates its absorption. All that has been stated thus far with regard to the use of alcohol in sickness applies to children as well as to adults. Of course no reasonable person would accustom healthy chil- dren to the use of alcoholic beverages ; but, in cases of disease, really good and pure wine or brandy can be advantageously employed, even for infants, either as a stimwlant, an antipyretic, or as an article of food, according to circum- stances. For external rise, alcohol has been superseded by various more modem agents, of wMch car- bolic and salicylic acids may be mentioned as the most important. In this connection the author cannot omit to notice one method of applying alcohol, suggested by Dr. Eichardson, namely, the treatment of diphtheria affecting the throat, by means of the inhaler, which projects the al- cohol-spray with considerable force upon the infected mucous membrane, causing it to pene- trate more deeply than any other caustic would be likely to do. 0. Einz (Bonn). ALCOHOLIC INSANITY. See AxcoHOi^ ISM, and Insanity. ALCOHOLISM.— Depinitioit. — This term is applied to the diverse pathological processes and attendant symptoms caused by the excessive ingestion of alcoholic beverages. These are very different if a large quantity is consumed at once or at short intervals ; or if smaller quanti- ties are taken habitually: and hence they are * English beer will contain a Uttle moro, bnt the writer has made no personal examination as to exactly how much. ALCOHOLISM. 27 subdiTided into those due to (a) acute, and (4) chronic alcoholism. To the acute forms of alco- holic poisoning belong the acute catarrh of the alimentary mucous membrane, rapid coma, some cases of delirium tremens, and certain special forms of acute insanity ; whilst to the ohronio class are referred the prolonged congestions, the fatty and connective-tissue degenerations of the various organs and tissues^ most cases of deli- rium tremens, nervous affections of slow onset and course, and the cachexia, which, in varying combinations, attend a continuously immoderate consumption of alcohol, .^TioLOQT.— That ordinary vinic or ethyl al- cohol, in any and every shape, is a sufficient ex- citing cause of such chrome affections is beyond a doubt ; moreover, we find that the more con- centrated the form in which it is taken, the more surely and rapidly are they induced, and that, although some beverages give » greater liability to certain forms of disease than to others, yet the ultimate tissue-changes produced by all are practically similar, and of a markedly degenerative character, The purest alcoholic fluids will also induce the acute forms ; but some of the phenomena observed in the worst cases of alcoholic poisoning hare been referred, with some probability, to admixture with fusel oil, essential oil of wormwood, cocoulus indicus, and other substances, more deleterious even than ordinary alcohol itself See Axcduol, and Absinthism. The predisposing causes of a sudden debauch, such as festive gatherings, example of com- panions, desire of relief from anxiety and melan- choly, &o., scarcely require mention. Acute alcoholic coma is generally due to the rapid consumption of a large quantity, but occasionally it is caused by taking a smaller quantity in the presence of some special condition, such as starvation, prolonged exposure to cold, or de- bilitating disease. Chronic habitual drinking is undoubtedly hereditary in many cases ; not that the ancestors have necessarily been drunkards, but that the family is of unstable nervous organisation, and that the neurotic taint which shows itself in other members in such affections as epilepsy, hysteria, insanity, is manifested in these cases by an intense craving for alcohol. Sometimes a pernicious education, by fostering habits of indulgence in early youth, has led to subsequent excess ; and the prescribing of stimulants has occasionally been productive of similar harm. In the experience of the writer, the exhibition of large doses in fevers and acute affections has never done this — indeed, in several instances, a great dislike to stimulants has been pro- duced — but the custom of recommending small quantities to young people and women as a remedy in hysteria, hypochondriasis, neuralgia, and allied disorders, or to relieve the fatigues incident to their daily life, cannot be too strongly protested against. The effect of occu- pation is very marked. Brewers, publicans, pot- men, and others who trade in alcohol are, as a class, very intemperate, and so fcequently are commercial travellers (Thackrah). Sedentary employments, being more monotonous, are more baneful than out-door occupations. IHeohanios 28 ALCOHOLISM. drink more freely than agrioultural labourers ; ■whilst night-labourers, cabmen, sailors when on shore, brewers' draymen, navvies, pitmen, and Duddlers consume an enormous amount of alcor Lolio fluids. Social infiuenees, such as domestic unhappiness, rate of wages, unhealthy dwellings, bad drinking water, or an intermittent supply, are important factors in the causation of drunken- ness. Under some circumstances, alcoholic ex- cesses do less injury than usual, for example, in persons whose employment' leads to copious sweating, or necessitates abundant exercise in a keen air ; and some constitutions resist their baneful influence to a remarkable extent. PATHOLoar. — A large amount of ardent spirits acts on the nerve-centres as a narcotic poison, and causes rapid death by coma. Smaller quan- tities produce intoxication, accompanied with or followed by an acute congestion and catarrh of the alimentary canal, especially of the stomach and duodenum. Habitual dram-drinking, by altering the chemical composition of the blood, and checking the normal changes of its cor- puscles, exerts an injurious influence on the nutrition of the tissues. This is incleased by the lessened consumption of food, and by the alterations in the calibre of the blood-vessels, set up at first by a special action on their vaso- motor nerves, and afterwards maintained by de- generation of their coats, as well, as frequently of the heart itself. Moreover, alcohol probably in- terferes directly with the nutrition of the cell- elements of the various organs as it circulates through them ; and it retards the elimination of effete materials — carbonicacid, uric acid, and urea. Anatomical Chaeactebs. — (o) Acute Aleohot- ism. — Dr. Beaumont thus describes the appear- ances which he observed in the stomach of Alexis St. Martin, after an excess of alcoholic Ktimulants : — ' Inner membrane morbid ; con- siderable erythema, and some aphthous patches on the exposed surface; secretions vitiated.' On another occasion, ' Small drops of grumous blood exuded from the surface, the mucous covering was thicker than common, and the gastric juices were mixed with a large propor- tion of thick ropy mucus and mueo-purulent matter slightly tinged with blood.' The post- mortem appearances in a case of rapid coma in a patient at King's College Hospital, after taking three pints of raw whiskey, were : — in- tense injection of the vessels of the pyloric end of the stomach and duodenum, with a peculiar blanching of the mucous membrane between them, giving rise to a vivid scarlet arborescent appearance on a white ground ; two ounces of bloody serum in the pericardial sac, and about sixteen ounces in the right pleural cavity (the left being obliterated by old adhesions) ; double pneumonia of the lower lobes ; extreme congestion of the kidneys ; and engorgement of the large veins over the posterior part of the brain. Contrary to the usual statements, no alcoholic odour could be detected in the brain, and there was no increase of fluid in the ven- tricles. The heart, liver, and kidneys were fal ty ; but these chrtnge* were probably of older date. In similar cases Dsverjie has noticed a bright rod colouring of the pulmonary tissue ; whilst Tar- dieu found pulmonary apoplexies in two cases, and meningeal bsemorrhages in five others. Death from acute delirium tremens leaves no niarked characters ; meningitis and coarse brain- lesions are extremely rare, whilst pneumonia is much more common. After repeated attacks, as well as in. old drunkards, fatty degeneration of the viscera, and various olier chronic changes are found. (6) Chronic Alcoholism. — The amount of fat in the blood is increased, or it becomes more visible. Chronic congestion and catarrh of the stomach, leading to atrophy of the gland-cells and an increase m the submucous connective- tissue, is very crostant, but chronic ulcer is not frequent. The liver is at first enlarged from congestion, and may continue so fi:om a sub- sequent infiltration with fat ; but more frequently it shrinks owing to cirrhosis. Lobar emphysema, chronic bronchitis, and hypostatic pneumonia are common. The heart is flabby, dilated, and presents fatty infiltration or even degeneration of its muscular tissue ; but it may be hypertrophied, probably as a result of coexistent disease of the kidneys. The arteries and endocardium are studded with atheromatous deposits ; the capil- laries are congested ; and the veins varicose. The kidneys exhibit the fatty, or, more com- monly, the granular form of Bright's disease. The muscles are pale and flabby, and even in the bonea formation of fat takes place at the expense of the bony texture. The nervous centres are atrophied and tough ; the convolutions are shrunken ; the nerve-cells and nerve-flbrgs are wasted ; and an increased amount of serous fluid exists in the ventricles and subarachnoid space. The abnormal adhesion of the dura mater to the cranium, : the large Facchionian bodies, the opaque arachnoid, and the thicken^ pia mater, all testify to an exaggerated develop- ment of fibrous tissue. Occasionally haemor- rhage into, or softening of, the brain, consequent on the diseased state of its blood-yessels, is met with. The increase of connective-tissue is es- pecially marked in spirit-drinkers, and explains the emaciated appearance, prematurely aged look, sunken cheeks, and wrinkled countenance which they generally present. The beer- and m7ie- drinkers, on the contrary, are loaded with fat, not only in the viscera, but in the subcutaneous tissue and the omenta ; and hence these subjects are corpulent, with oily skins and prominent ab- domens, even when the face and extremitiee are wasted. Gouty deposits are also frequent. These differences, however, are not nearly so absolute as is maintained by many writers. The presence of a variable amount of dropsy, a congested pharynx, chronically-inflamedi con- junctivae, turgid capillaries, and occasionally papules of acne rosacea on the face, complete the morbid anatomy of the confirmed toper. The autopsy in alcoholic insanity disclose!! no specific characters. Symptoms. — 1. Acute Intoxication. — In thja state the successive and varying mental phenp- mena, the disorders of common and special a^^ise, and of the motor apparatus, are well known. These are followed by uneasy sensations and tenderness in the epigastrium, vomiting or retching, _ headache and vertigo, with dimness and occasionally yellowness of vision on stooping ALCOHOLISM. 20 ond rising again. The tongue is furred, the uppetite is lost, and there is a constant feeling of thirst. The arine is copious and pale, but afterwards becomes scanty and loaded with lithates. The countenance is sallow, and the general lassitude and depression are very marked. 2. Acute Akoholio Coma. — In slight cases of this condition prolonged drowsiness is the chief symptom : but in the more severe forms the patient is quite insensible ; the power of motion is in complete abeyance; the breathing is ster- torous ; the face is usually pale, the features re- maining symmetrical; the pupils are generally dilated, though they may be contracted or even unequal ; the pulse is slow and laboured ; the skin feels cold and clammy ; and the temperature is low —in one case it fell to 92° Fahr. There may be albuminuria ; and occasionally the urine and fseces are passed involuntarily. 3. Chronic Alcoholism. — The earliest symptoms of this form are muscular tremors, especially on waking ; disturbed sleep ; noises in the ears ; dull headache ; occasional vertigo ; and disorders of vision. If there be also a foul breath, slightly- jaundiced coiy'unctivse, watery eyes, and flabby features, with or without papules of acne rosacea around the nose and mouth, the combination is very characteristic. Irritative dyspeptic symptoms — the wmitt^s maiutinua of Huteland — and the signs of commencing or actual cirrhosis, of Bright's disease, or of fatty heart, frequently co- exist. As the affection advances, the insomnia and tremors increase ; the mental condition be- comes impaired ; a striking deficiency of will and uncertainty of purpose are noticeable ; the gait becomes ataxic ; and the patient has a constant feeling of dread and ansiety. 4. Delirium l^emens. — This form of alco- holism occasionally supervenes on a single de- bauch, but it much more frequently afiects the chronic drinker. It generally comes on during a drinking-bout, but this may have terminated before the attack commences. In some cases it is undoubtedly determined by prolonged ab- stinence from food, mental distress, surgical in- jury, or the onset of an acute disease, along with the ingestion of alcohol ; but in others no cause but the last can be traced. The first stage is indicated by inability to take food ; marked anxiety and restlessness; tremor of the voluntary muscles; furred and tremulous tongue; cool skin, which is frequently bathed in perspira- tion ; cold hands and feet; and a soft weak pulse. There is complete insomnia, or short periods of sleep are interrupted by terrifying dreams, and the patient's nights are tormented with visions of horrid insects, reptiles, and other ob- jects pursuing him and eluding his attempts to escape from them or to seize them. Illusions of hearing are not uncommonly added ; but the sense of smell is much more rarely involved. If there is no improvement, these not only haunt his nights, but persist in the daiytime; he becomes more incoherent, his mental alienation increases, and attempts at suicide are com- mon. The pupils are now minutely contracted, but there is no intolerance of light. The pulse quickens, and is very feeble or even dicrotic ; end the general symptoms become more marked. A prolonged sleep may occur in this stage, and the disease thus terminate. If it continues, the strength fails : the pulse becomes small, weak, and thready ; the tremor increases ; the tongue gets dry and brown in the centre ; persistent coma-vigil and subsultus tendinum come on ; the patient talks incessantly, and picks at the bed- clothes ; and death is ushered in by a delusive calm, or takes place in a paroxysm of violence. The writer has known cases in which the attack of delirium tremens always began by several severe epileptic fits. 6. Alcoholic Insanity. — The forms of insanity caused by alcoholism are acute mania animelan- cliolia, chronic danentia, and oinomania. In the first homicidal impulses, and in the second strong suicidal tendencies, date to actual delusions and not to mere passive terrors, are added to the other signs of delirium tremens. Oinomania is a peculiar form of insanity, in which the patient breaks out into paroxysms of alcoholic excess, attended with violent, strange, or even indecent acts, due to apparently uncontrollable impulses. The attack lasts a few days, and is succeeded by a long interval of sobriety and chastity. These patients have generally some hereditary taint ; and not unfreqnently evidences, though often slight, of a morbid mental state may be detected in the intervals, if very carefully looked for. See Iksamity. CoMPijcATioNS.^Most of these have been jiointed out, but chronic drinkers are especially liable to pneumonia of a low type, and to rapid phthisis. Delirium tremens is very rarely com- plicated with meningitis ; acute alcoholic gastric catarrh may be followed by jaundice ; and cere- bral haemorrhage may come on in a drunken fit. Temporary albuminuria is occasionally caused by the ingestion of large quantities uf spirits, and even of beer. Diagnosis. — The diagnosis of acute alcoholic gastric catarrh, of insanity from alcohol, and of oinomania depends on obtaining a true history. Acute alcoholic coma can only be diagnosed with certainty by emptying the stomach and examining its contents. Mere odour of the breath is quite faUacious ; and the writer attaches but little importance to the state of the pupils, or to the general features of the coma. Convul- sions sometimes usher in the condition; and apoplexy may arise from the accidental rapture of a bloodrvessel whilst a person is drunk. Opium-poisoning can only be satisfactorily elimi- nated by examining the contents of the stomach. Ursemic poisoning may be diagnosed, by testing the urine, though here an element of uncer- tainty is introduced by the occasional occurrence of albuminuria in alcoholic, cases; the pre- sence of hypertrophy of the heart, of dropsy, of casts in the urine, or other changes typical of Bright's disease, must decide the question. De- lirium tremens is occasionally separated with difficulty from some forms of insanity not caused by drink; but in these cases delusions, not mere terrors or hallucinations, are of primaiy im- portance. The delirium of acute fevers and pneumonia may be mistaken for delirium tremens ; but the pyrexia, history of the ease, and physical condition, of the patient will guide to a correct diagnosis if the possibility of error 80 ALCOHOLISM. is remembered. Ckronio alcoholism has been mistaken for other chronic nervous affections^ such as locomotor ataj^,, chronic softening and multiple sclerosis of the nerv^-cantres, para- lysis agitans, chronic tremors from metallic poisons, senile dementia, and commencing general paralysis. In all these maladies, special symp- toms are present, besides those common to them and to chronic alcoholism. Pkoonosis. — In the acute forms pf alcoholism the prognosis is favourable so far as the imme- diate attack is in question. In acute coma, the patient generally, but, by no means invariably, rallies from the state of insensibility ; but he may die from the supervention of a very rapid pneu- monia. The prognosis in delirium tremens is favourable in young subjects ; but its gravity increases with every attack, and , with the co- existence of disease of the viscera, especially of the heart, liver, or kidneys. Patients with marked symptoms of fatty heart, or in whom pneumonia sets in, but rarely recover. Chronic alcoholism may be temporarily arrested; but the ultimate issue is unfortunately as a rule only too certain, for the habit is in most cases too strong to be broken off, or even to be checked for any lengthened period. Mental impairment, persistent tremors, ataxy, and signs of coarse brain-lesions, are especially significant of a speedy termination. Tkeatment. — The aaate gastrie catarrh is most rapidly subdued by washing out the stomach with copious draughts of tepid water, and then giving a saline purge. All forms of alcohol should be rigidly abstained from ; and the diet must be simple, and taken in a fluid form for a day or two. Passive exercise in the open air, or, if the patient be vigorous, a brisk ride on horseback, is veiy beneficial. In cases of acute coma the stomach should be at once emptied by means of the stomach-pump. Cold afRision, followed by energetic friction and the application of bottleff filled with warm water, so as to keep up the temperature, will generally revive the patient. Galvanism, in the form of the interrupted current, may often be employed with advantage. If the patient be strong, a smart purge, or, if weak, a milder one, will be all the after-treatment that is necessary. Delirium tremens must be treated differently in the' young and in the old. In first attacks iti young subjects, complete abstention from al- cohol, light and easily assimilated food (milk diet), moderate purgation, and occasionally antimony in doses of one-eighth of a grain, carefully watched, hare been most efficacious in the writer's hands. If the patient has two or three restless nights in succession, bromide of potassium (thirty grains), or chloral hydrate (twenty grains), may be given at intervals of four hours, until sleep is pro- cured ; but as the disease is spontaneously curable, sedatives must not be pushed. An ex- perienced attendant should be always present, but no form of mechanical restraint is permissible. In older cases, a mild purge should begin the treatment; and light but very nourishing food should be administered at short intervals. Milk, beef-tea, raw eggs beaten up with milk, stnmg eoups, and such articles are to be given freely ; when, by careful management and good nur!,ing, ALEPPO £VIL. a very severe attack may be tided over, and natural sleep will return in from three to five days. The early administration of sedatives is to be deprecated, but should the _ restlessness persist, in spite of careful and assiduous feed- ing,, a full dose of laudanum (ni xxx.— xl.] at bed-time is of great value. In the absence of albuminuria, lung-complications, , or any sign of failure of the heart's action, the writer prefers this drug to other sedatives. If the opium alone fail, its combination with an alcoholic stimulant (brandy, whisky, or stout) often suc- ceeds. If there be any tendency to syncope, or if pneumonia should come on, as well as in cases complicated with shock, as in surgical injuries, a free use of stimulants is imperative. Hypo- dermic injections of morphia, and large doses of digitalis, are recommended by many autho- rities; but the writer has seen great harm attend their free exhibition. The cautious inhalation of chloroform vapour has occasionally cut short an attack by inducing sleep, but it much more frequently fails. Mechanical restraint is seldom, if ever, necessary, if the patient be properly nursed and attended to. All methods of self- destruction must be carefully guarded against ; and a padded room, when available, is of the utniost benefit. The great desideratum in chronic alcoholism is to substitute an easily-digested and nourishing diet for the alcoholic stimulants, which can then be safely dispensed with altogetlier. The prac- titioner's judgment, and his knowledge of the cuisine, are very important in the management of these cases. Strong meat-soups and good speci- mens of the concentrated preparations of meat are of great value. The strictly medicinal treatment will consist in the administration of bitter tonics, such as nux vomica, quinine in small doses, ealumba, or gentian ; with car- minatives, such as spirit of chloroform, ar- moracia, and capsicum. Alkalis, effervescent mixtures, and hydrocyanic acid are peculiarly useful if the stomach is irritable. The condi- tion of the liver and bowels should be carefully regulated. Bromide of potassium is in general the best sedative to employ against the insomnia, though chloral hydrate is more certain ; but the latter should only be given occasionally, lest the patient fall into. the habit of frequently resort- ing to it. In long-standing cases, cod-liver oil, arsenic in small doses, and oxide of zinc have all done good, but they require a long and pro- tracted administration. Phosphorus has been of no use whatever in the cases in which the writer has tried it ; but small doses of the more easily assimilable preparations of iron are occasionally well borne, and are then most useful. The craving for drink, if urgent, may be checked by small doses of opium, but this drug must be exhibited with extreme caution. Ju- dicious supervision, and, in inveterate cases, a residence in a proper asylum, are the only means from which any permanent benefit can be ex- pected. The treatment of insanity induced by alcoholism will not differ from that recommended in other forms, except in an enforced abstinecce from its cause. John Cuknow. AI>EFFO EVUi. See Seui Bon,. ALGID. A-IiG-H) {dgidut, cold). — A word implying extremR coldness of the body, used only when it arises in connection with an internal morbid state, such as cholera, or a special form of malignant remittent fever. AtiQIEBS. — ^Warm winter climate. Mean wintertemperature 59° F. , liable to rapid changes. Heavy rains not infrequent. See Cumatb. ALIMEITT. — ^Food or aliment furnishes the elements required fee the growth and main- tenance of ^he organism ; an£, through its action with the sther life factor — air, forms the source of the power manifested. The aliment of organisms belonging to the ve- getable class is derived from the inorganic king- dom. Under the influence of the sun's rays the inorganic principles are applied to growth, and constructed into organic compounds. This con- stitutes the main operation of vegetable life, and in it we have the source ofthe aliment of animals, which can only appropriate organic compounds, and which either directly or indirectly derive these compounds from the vegetable kingdom. As the solar force employed in the construction of organic compounds, through the agency of the ve- getable organism, becomes locked up in the com- pound formed, such compound represents matter combined with a definite amount Of latent force. In the employment, therefore, of organic matter as aliment by animals, we have to look upon it not only as yielding the material required for the ciinstmction and maintenance of the body, but as containing and supplying the force which is evolved under various forms by the operations of animal life. Aliment constituting the eouroe from which the several elements belbnging to the body are derived, it follows that to satisfy the require- ments of life it must contain all the elements that are encountered. It is not, however, with the elements in a separate state that we have to deal, but with the products of nature in which they are variously combined. The alimentary productt as supplied by na- ture are resolvable by analysis into a variety of definite chemical compounds. These constitute the aUmentary prvttciples. Some are common to both animal and vegetable food, as for instance albumen, caseine, fats, &c. ; others axe peculiar to either the animal or vegetable kingdom. Starch, for example, is met with only in vegetable, and gelatine only in animal products. With reference to the alimentary principles, it must be understood that in no case do they exist in natural products in an isolated form, and no single alimentary principle is capable of sup- porting life. Although, however, it is with the alimentary products as a whole that we are prac- tically concerned, yet, regarded from a scientific point of view, a knowledge of these constituent principles is required, to enable us to assign to them their proper value as alimentary articles ; and for the purpose of systematic consideration some kind of classification is needed. Classiticatioh. — ^Prout classified the consti- tuent principles of food into four groups, which he named (I) the aqueous; (2) the saccharine; (8)_ the oleaginous ; and (4) the albuminous. This classification is defective, inasmuch as it ALIMENT. 31 omits from consideration saline matter, which 18 equally as essential to nutrition as any other part of an alimentary product. The saccharine and oleaginous groups also stand as primary and independent divisions, whilst physiologically they are related, and may be conveniently con- sidered under a combined heading. Liebig proposed a classification based on phy- siological principles; and, taking into account only the organic constituents qf food, grouped them under the heads of (1) plasiio elements of nutrition ; and (2) elements of respiration. His plasiio elements of nutrition comprise the, nitro- genous principles ; and to these he assigned the office of administering not only to the growth and renovation of the tissues, but also to the produc- tion of muscular and nervous power. Believing that the source of these powers issued from the oxidation of the respective tissues, he held that the exercise of muscular and nervous action created a corresponding demand for nitrogenous alimentary matter, which thus became invested with an importance that led it to be regarded as affording a measure of the value of an alimen- tary article. £y recent experimental research this view has been found to be untenable. The nervo-muscular organs are now looked upon as holding the position of instruments, by whose agency the force liberated by chemical action is made to manifest itself under certain other forms; and what is wanted for the purpose is simply oxidisable organic material, which may be de- rived from non-nitrogenous as well as nitro- genous food. The elements of respiration or, as they were afterwards more appropriately styled, the cahrifadent principles, represent the organic non-nitrogenous constituents of food. Their destination, according to Liebig, was heat- production. It is now maintained, however, as stated above, that they play a part in connection with nervo-muscular action ; and it may be also said that they are to some extent concerned in tissue-development. From the considerations set forth, Liebig's classification loses the scientific value it was at one time supposed to possess. The following grouping of the alimentary principles based on chemistry furnishes a classi- fication which involves no theoretical proposi- tion, and is practically convenient : — Food is primarily divisible into Inorganic and Organic principles. The Inorganic principles consist of water, and the various saline matters required by the sys- tem. They are as much needed for the support of life as the organic portion of food. The Organic principles are sub-divisible into Nitrogenous and Non-nitrogenous ; and the Xon- nitrogenous are again further sub-divisible into Hydro-carbons and Carbo-hydrates. The Nitrogenous principles contribute to the growth and nutrition of the various bodily textures, and famish the active agents of the se- cretions. They also undergo resolution in the system into urea, which is excreted ; and a com- plementary hydro-carbonaceous portion, which is susceptible of application to force-production. They are thus capable of administering to all the purposes fulfilled by the organic portion of an aliment. The Hydro-carbons or Fats are applied to the 82 ALIMENT, production of heat and other forma of force. 'ihaj seem also to be essential to tissue-de- velopment generally, besides yielding the basis of the adipose tissue. The Carbo-hydrates (starch, sugar, gum, &o.) contribute to the formation of fat, and are also applied indirectly if not directly to force-produc- tion. There are a feir principles, such as alcohol, the vegetable acids, and pectin or vegetable jelly, which do not strictly fall within either of the preceding groups. Alcohol occupies a chemical position intermediate between the fats and carbo- hydrates; whilst the others mentioned are more highly oxidised compounds than the carbo- hydrates. All alimentary products in the form supplied by nature contain organic and inorganic prin- ciples, and the organic principles comprise more or less of thei nitrogenous and non-nitrogenous kinds; but the non-nitrogenous do not neces- sarily, and indeed do not generally, include both hydro-carbons and carbo-hydrates. In milk, however, which may be regarded, from the posi- tion it holds in nature, as furnishing a typical representation of an alimentary article, principles exist belonging to each of the groups enumerated in the above classification. Set Xivsi. F. W. Pavt. AI.IHENTAB7 CAITAL, Diseases of. See Digestive Obqans, Diseases of; and the several organs. AIiKAIiINITlT. — The reaction of human blood is always alkaline; and, though the normal degree of alkalescence has not yet been deter- mined, it is probable that, like the temperature of the body, it is tolerably constant. In dis- ease considerable variation, no doubt, occurs, but still the blood is always found alkaline, Fettenkofer and Voit found the serum of blood acid in a case of leukaemia some few hours after death, but not during life ; and Dr. Garrod states that in chronic gout the serum may become some- what neutralized, but never acid. F. Hofiinan has also found that the blood retains its alka- linity with great obstinacy ; he fed pigeons for a considerable length of time on food yielding only acid ash, but the animals siifTered from blood-poisoning before the alkalinity of the serum was neutralized. The alkalinity of the blood is maintained by the constant passage into it of the alkaline salts of the food, and of alkaline carbonates derived from the oxidation of the lactic, oxalic, and uric acids furnished by the disintegration of the tissues. The blood is pro- bably prevented from becoming too alkaline by the withdrawal of iti alkaline salts by the alka- line secretions, namely, the saliva, the bile, and the pancreatic fluid ; whilst the acid salts, which, if accumulated, would tend to depress its normal alkalinity, are removed by the acid secretions, namely, the sweat, the gastric juice, and the urino, and by the exhalation of carbonic acid from the lungs. It has been shown that the withdrawal of acid by one secretion has a decided effect on tho reaction of other secretions; thus the saliva becomes more alkaline during digestion, when the stomach is pouring out the acid gastric juice; and Dr. Sence Jones has shown that ALKAUS. during digestion the acidity of the nrine is lessened. A similar relationship is also shown to exist between the elimination of carbonic acid by the lungs and the acidity of the urine, the latter falling as the former is increased, and vice vered. The importance of a proper degree of alkalescence for the blood is ob- vious, when we consider that this condition increases the absorption-power of its serum for gases, and is necessary to maintain its albu- min in the liquid state, whilst oxidation is always more perfectly performed in alkaline solutions. ALKALIS. — DEnNiTiON. — Inorganic sub- stances, which turn syrup of violets green, and turmeric brown ; and restore the blue colour to litmus which has been reddened by acids. They combine with acids to form salts, and their car- bonates are soluble in water. Enumeration. — The only substances which correspond with the above definition are — ^Potash, Soda, Lithia, and Ammonia. The alkaline earths —Lime, Magnesia, Baryta, and Strontia, and the organic alkaloids, have a similar action on vege- table blues and yellows ; but the carbonates of the former group are almost insoluble in water ; whilst the latter contain carbon, and are there- fore classed with organic substances. Pboferties. — Ammonia is distinguished from the other alkalis by its volatility. The non- volatile alkalis are readily recognised by their spectra; and by the colour they impart to tho blowpipe flame, potash giving it a violet, soda a yellow, and lithia a carmine colour. Potash and soda are present as constituents of the body in considerable quantities ; ammonia exists to a smaller amount ; and lithia probably in traces. Soda is found chiefly in the blood, potash in the muscles. Action. — ^When applied to the skin dilute alkalis and their carbonates act as rubefacients. Pure ammonia is a vesicant, and potash and soda have a caustic action. £oth caustic potash and soda absorb water from the tissues, and form a corrosive fluid, which destroys the parts around, as well as that to which the caustic has actually been applied. To prevent this effect they are sometimes mixed with lime, which absorbs the water. A mixture of potash and lime forms the Vienna Paste. When inhaled, ammonia causes irritation of the respiratory passages, and in- creased secretion of mucus. This irritation ex- cites reflex contraction of the blood-vessels and consequent rise of blood-pressure. When swal- lowed in quantity, the caustic alkalis and their carbonates produce symptoms of irritant poison- ing. In the case of ammonia these symptoms maybe accompanied by those of inflammation of the air-passages, caused by the irritant vapour. The best antidote is dilute acid, such as vinegar. In small quantities and diluted, alkalis increase the secretion of gastric juice. After absorption into the blood they render this fluid more alka- line ; whilst potash appears especially to accele- rate tissue-change, and is accordingly classed among the alteratives. When injected directly into the blood, potash acts specially on the mus- cles, which it paralyses. Ammonia stimulates tho motor centres in the brain and spinal cord, tho ALKALIS. respiratory centre in the medulla oblongata, and the accelerating nerves of the heart. When injected into the veins it- therefore causes con- Tulsions like those of strychnia, and quickening of the respiration and pulse. Alkalis are chiefly excreted by the urine; and potash, soda, and lithia lessen its acidity, or render it alkaline. Ammonia is partly excreted unchanged, but a portion passes out in the form of urea ; and it does not render the urine alkaline like the others. Potash and lithia act as diuretics ; soda to a less extent ; and ammonia least of all. The diuretic action does not depend on any change in the blood-pressure. Potash and ammonia are diapho- retic. Potash lessens the tenacity of mucus. Uses. — Dilute solutions of potash and soda relieve itching in skin diseases. Caustic potash or soda is Used to destroy warts ; to cauterize poisoned -wouiids and ulcers; to open hydatid cysts in the liver ; and to establish issues. Am- monia neutralizes the formic acid which renders venomous the stings of bees, ants, and mosquitos, and is therefore applied to relieve the pain which they cause. The intravenous injection of am- monia has been recommended as an antidote in snake-poisoning ; but the value of the remedy is not established. Mixed with oil, so as to form a liniment, ammonia is used as a rubefacient in sore throats, bronchitis, rheumatic pains, and neu- ralgia. It is inhaled to relieve headache ; as a restorative in synSope and shock, when if raises the blood-pressure ; and to facilitate expectora- tion in chronic bronchitis. . Alkalis administered after meals act as antacids, and relieve heartburn. When' given before meals they increase the secre- tion of gastric juice, quicken digestion, and relieve weight at the epigastrium, pain between the shoulders, and flatulence. Bicarbonate of soda is \isually given for this purpose, but when the stomach is very irritable liquor potassse is pre- ferred, as it is considered to have a sedative action on the mucous membrane. Alkalis appear to lessen the transformation of glycogen into iiugar, and they are used on this account in dia- betes. Liquor potassas sometimes helps to reduce obesity. Alkalis are used in the treatment of scrofula, rheumatism, gout, and lithiasis ; but in the two last- mentioned lithia is considered the most valuable, whilst potash is preferred to soda, as the urate of lithia is most soluble, and the urate of soda least so. The salts of certain organic aoiiJs, such as the acetate or citrate, may be employed as remote antacids to render the urine alkaline, as they undergo combustion and are converted into carbonates in the blood. Alkalis are given to lessen the acidity of the urine in inflammation of the bladder or urethra, and potash is employed as a diuretic in dropsies. On account of its stimulating action on the heart and respiration, ammonia is administered in adynamic conditions and in chronic bronchitis. T. Laudee Betintok. AIiEAIiOIBS and otber ACVTVE PBIWCIi'IiBS.— DEFiNmoN.— An alkaloid is a ^substance formed in the tissues of a plant or of an animal, having a definite composition as re- gards the proportions of the chemical elements of which it is composed, and capable of combining, like an alkali, with acids to form salts. 3 ALKALOIDS. 33 Besides alkaloids there are other active prin- ciples found in plants, which have also a power- ful influence on the animal economy but dii not possess all the chemical properties jus'- stated. Chemical Composition and Eblatiows. — These are briefly expressed in the above defini tion. Thus morphia, one of the alkaloids oi opium, has always the chemical composition represented by the formula C„H,9N0j, and it may unite with acetic acid to form acetate of morphia, just aspotalsh may unite with the same acid to produce acetate of potash. But the em- pirical formula C|,H,jNO, represents only the percentage composition of the substance in tho simplest numbers, and does not express how tho atoms of the different elements are related to each other. For, just as ethylio alcohol, with the composition C'H'O, is believed by the chemist, from its behaviour towards other bodies, to contain a 'radicle,' or group of atoms, C'H', having certain chemical properties resembling those of a base, such as potassium, K ; and just as this radicle, OjH, may replace one of the elements of water, so as to form alcohol (C'H» + H'O = ^^'o + H) ; so chemists have good reason for believingthat alkaloids belong to the group known as amines or amides, which are really ammonia, NH.', in which one oi more of the atoms of hydrogen' are replaced by a radicle or radicles. It is impossible, however, in the present state of knowledge, to represent the true chemical composition of alkaloids, the exact oon- stitutionof the'radicles being still unknown. It is obvious that two or more alkaloids may resemble each other in percentage composition, and still be very different, both in their chemical structure and, necessarily, in their physiological action. Thus strychnia, G^Ji^i^i^v quinia, CaiHjjNjOj, and cinchonia, CjjHjjNjO, differ only in a few atoms of carbon or of oxygen, more or less ; but they have different physiological ac- tions, showing that their chemical structure, which is not indicated in these formulae, must also be different. The physiological action of an alkaloid may also be modified by combining it with another substance. Thus, as was pointed out by Crum-Brown and Praser, compbunds of : strychnia with methyl, ethyl, and amyl, do not present the well-known physiological action of •that substance, but one analogous to that of woorara. Enumeeation. — The alkaloids and other ac- tive principles most familiar to the physician are: — Morphia, Apomorphia, Narceia, Codeia, Thebaia, Narcotin, Papaverin ; Atropia, Hyos- cyamia, Daturia ; Nicotin ; Conia; Physostigmia; Strychnia, Brucia ; Quinia, Cinchonia, Beberia ; Caffein ; Aconitia, Veratria ; Digitalin ; Curarin ; Muscarin ; Santonin ; and Ergotin. SouECEs. — The majority of alkaloids are formed by plants. The function which they subserve in the economy of the plant is not known. Some plants produce only one alkaloid,' while in others two or more may be formed. A few of the alkaloids have been produced syn- thetically by tlie chemist. PhysjoIogicai, Action. — Alkaloids have various dtigrees of physiological activity wheO 34 A1KA.L0IDS introduced into the animal body. Many are slow in their action, and a large dose is required to produce any observable effect ; while others act aiore rapidly, and are sopotent that even a minute dose may destroy life. Compare, for example, nareotin, one of the alkaloids of opium, with nicotin, the alkaloid of tobacco. Twenty to thirty grains of the former have been taken by . the human subject without producing any marked symptoms, while the twentieth part of a grain of the latter may induce symptoms so severe as to threaten death. It is also well known that alkaloids may have a different kind of action on different animals. Thus one-fourth of a grain of atropia will produce serious symptoms of a com- plex character in a dog, while three or even four grains may be given to a rabbit without causing any more marked effect than dilatation of the pupil. In considering the physiological ac- tions of these substances the following general- izations may. in the present state of science, be made tentatively: — 1. As a general rule, the more complex the organic molecule, and the greater the sum of the atomic weight, the more intense will be the action of the substance. This has been shown in experiments on the action of the chinoline and pyridine series of bases by McKendrick and Dewar. 2. Substances which split up quickly into simpler bodies, produce rapid but transient physiological effects, whereas substances which resist decomposition in the blood or tissues may produce no appreciable results for a time; but when they do begin to break up. the effects are sudden and violent, and usually last for a considerable time. 3. Al- kaloids have frequently a double action on dif- ferent parts of a great physiological system, and their action in a particular group of animals will depend on the relative degree of develop- ment of the parts of the system in that group. Thus most of the alkaloids of opium have such B double action— a convulsive action resembling that of strychnia, due to their influence on the spinal cord or on the motor centres in the brain ; and a narcotic or soporific action resembling that of anaesthetics, due to their influence on sensory centres in the brain. Hence, in animals where the spinal system predominates, as in frogs, these alkaloids act as eonvulsants ; while in the higher mammals their principal action is ap- parently on the encephalic centres, which have now become largely developed. Passing to the consideration of the action of the individual substances, we cannot do more than give, by way of example, a brief rkumeoi our knowledge regarding a few of them. 1. Morphia — C„H,5NOs— an alkaloid of opium. In the frog this substance has an action resembling that of strychnia. At first there is a state of agitation, followed by tetanic spasms : finally, all reflex actions, including those of tlie heart and of respiration, are paralysed. Pigeons have been found to possess a remarkable power of withstanding the influence of this drug — an ordinary-sized bird requiring about two grains to kill it. Rabbits become partially somnolent, show a tendency to reflex spasms, and tolerate a large dose — say about one-half to one grain per pound weight of the animal. In the dog the intravenous injection of even one-tenth of a grain (for a small animal) causes agitation fol- lowed by sleep ; the pulse and respiratory move- ments are slowed ; the smaller arteries become (at least during one stage) contracted, so as to cause an augmentation of general blood-pressure; the pupil is contracted ; and, if the dose be large, death may be preceded by convulsions. In the higher mammals morphia acts chiefly on the sensory apparatus, both peripheral and central. 2. Other alkaloids of opium have also been investigated.— (a.) Haroeja, CjjHjjNQa, is a pure hypnotic, causing profound sleep. Even in large doses it does not produce convulsions, (i.) Codeia, CuH^iNO,, has an action like that of morphia. \c.) Thebala, CjgHjiNO,, causes tetanic convulsions, thus resembling strychnia. (d.) Narootin, CjjHjjNO,, is slightly narcotic, but strongly convulsant. (c.) Faparerin, CjuHjiNO,, causes a somniferous action like that of narceia. Apomorphia, 0|,H,,N02, a deri- vative of morphia, has none of the characteristic actions of that substance, but acts chi efly as a vas- cular depressant and as an emetic. It is evident, therefore, that opium, which may contain more or less of all of these substances, must have an action on the body of a very complicated cha- racter. 3. Stryohnia, C^^'B^^fi^ — the alkaloid of Strychnos nux vomica. In the frog very mi- nute doses cause convulsions of all the volun- tary muscles, excited by peripheral irrita- tion. These convulsions are due to the action of the poison on the spinal cord, as they persist after decapitation. In warm-blooded animals the reflex character of the convulsions is less evident ; they have more of a tonic character, and chiefly affect the extensors. The exact modns operandi of the poison on the cord is un- known, but in some way or other it heightens its reflex sensibility. Death is usually the result of asphyxia from arrest in spasm of the respira- tory mechanism, but it may result from exhaus- tion. Brucia, C23H28N.^04, another substance found in nux vomica, appears to have an action like that of strychnia, but more feeble. 4. Atropia, CjjHjjNOa, — the alkaloid of Atropa belladonna. In the frog it causes tetanic reflex spasms. Herbivorous animals, as a rule, have a tolerance of this poison, so that its effects are best studied in carnirora. Even in these the action is somewhat uncertain. Kespiration may be paralysed without general convulsions: the pulse is quickened by paralysis of the inhibitory action of the pneumogastric nerve on the heart ; and the arterial pressure is increased. After very large doses the arterial pressure may be dimin- ished with paralysis of all parts containing in- voluntary muscular fibre. Secretion is dimin- ished. The pupil is dilated apparently by » direct influence of the poison on the centres or nervous arrangements in the iris itself, as the effect may be observed even in an eye removed from the head. Hyoseyamia, the alkaloid of Hyoscyamus niger, and Daturia, the alkaloid of Datura stramonium, have an action like that of atropia. 6. Digitalin, C2,H„0,5,— the active principle of Digitalis purpurea. A large dose causes slow- ing of the heart's action, and if the dose bo in- creased the heart will be arrested in diastole. ALKALOIDS. and will not respond to direct excitation. With medium doses there is a period of acceleration of the heart's action, but this period may rapidly pass into that of slowness just mentioned. This action on the heart has not yet been clearly accounted for, and it remains to be de- ;idad -whether it be due to the influence of the drug on the terminations of the pneumogastric, or of the sympathetic, or on the intracardiac ganglia themselves. Coincident with the action on the heart, the smaller arteries are contracted and . the arterial tension is increased. Digitalis would appear to have little effect on involuntary muscle, but it exerts a potent action on voluntary muscle, which, after small doses, becomes feeble in con- tractile power, while large doses may abolish contractility altogether. 6. PhysoBtigmia, OuHji'NaOj, — the active substance of Physostigma venenosum, or Calabar bean. As has been pointed out by Professor Fraser, this alkaloid has an action antagonistic to that of atropia. Sensibility and conscious- ness remain until death ; the voluntary muscles are paralysed ; involuntary muscles are said to show tetanic contractions ; respiration is at first accelerated, and afterwards slowed ; the vessels become alternately dilated and contracted; secre- tion, especially that from the lachrymal and sali- vary glands, is increased ; and the pupil is con- tracted. It appears to paralyse the extremities of the motor nerves, in this respect resembling curare. 7. Ourare is a resinous substance, containing an alkaloid, Cuxaxin, of the composition C,|,H,5N, obtained from certain parts of South America, and used by the natives of these regions as an arrow-poison. It is probably obtained from cer- tain plants belonging to the genera Strychnos and PauUinia. Its distinctive physiological action is abolition of the power of all voluntary movement, in consequence of its action, as was proved by Claude Bernard, upon the peripheral terminations of motor nerves — the " terminal plates " of muscle. Eespiratory movements are arrested in consequence of paralysis of the muscles of respiration, but the heart may con- tinue to beat for a considerable time. If arti- ficial respiration be established, the circulation may be maintained for several horn's while' the animal is completely under the influence of the substance. Ail the secretions are increased, and the mean temperature falls. 8. Musoarin, the alkaloid of Agaricus mus- carius, causes arrpst of the heart's action in dia- stole, an effect which may be removed by the influence of atropia, thus affording an instance of physiological antagonism. In warm-blooded animals muscarin slows the heart's action ; the blood-pressure falls ; respiration is first embar- rassed, and may be completely arrested ; parts containing involuntary muscle are in a state of tetanic spasm ; the pupil is contracted ; and secre- tion is increased. 9. Sajitonin, CisHjbOj, the alkaloid of Arte- mesia santonica, may cause in man nausea, vomiting, hallucinations, vertigo, and a peculiar state of visual sensation — the field of vision usually appearing yellow, but sometimes violet. It is said tbat the stage of violet rapidly passes intc that of yellow, and therefore it is probable ALTEEATIVES. •66 that santonin may first excite the retinal fibres sensitive to violet (according to Thomas Young's theory of colour-perception), and afterwards para lyse them. In large doses, santonin causes loss of consciousness, tetanic convulsions, and death. 10. Ergotiu, the active principle of Secale cornutum, causes contraction of the smaller blood-vessels, contractions of the uterus, and slowing of the pulse ; and the animal may die in consequence of arrest of the action of the heart. 1 1 . Quinia, CjoHjiNjOj, one of the alkaloids of Cinchona, in small doses accelerates the heart's action in the warm-blooded animal ; in moderate doses it slows it ; and in large doses it may ar- rest it, and cause convulsions and death. Research shows that its action is essentially upon the cen- tral nervous system. It destroys all microscopic animal organisms, apparently killing vibrios, bacteria, and amoebae ; but it seems to be with- out action on humble organisms belonging to the vegetable kingdom. It arrests the movements of all kinds of protoplasm, including those of the colourless corpuscles of the blood. It arrests fermentive processes which depend on the pre- sence of animal or vegetable organisms, but it does not interfere with the action of digestive fluids. 12. Cinohonia, CjjHjjNjO, is said to have an action similar to quinia, but much more feeble. Further research is needed on this point. Jomr G-. McKendeick. ALOPECIA. ! Baldness. ALPHO S and ALPHOIDES {aXxj)hs, white), terms signifying white and white-looking, are associated with the whiteness of the disks of common Lepra ; hence Lepra alphas and Lepra alphoidee. See Lepra.. AIiPHOSIS (ftAi/>!)j, white). — Whiteness, or the process of turning white. See Achboka. AIiTEKATIVES. — Definition. — Medicines which gradually restore the nutrition of the body to a healthy condition, -without producing evacua- tions, or immediately exerting any very evident action upon the nervous system. Enumeration.— The principal alteratives are —Nitric and Nitro-hydrochloric acids ; Chlo- rine and Chlorides ; Iodine and Iodides ; Sulphur and Sulphides; Potash and its salts; Mercury and its salts; Phosphorus; Hypo- phosphites ; Antimony ; Arsenic ; Taraxacum ; Sarsaparilla ; Hemidesmus and Guaiacum ; Me- zereon and Dulcamara. Action. — Healthy nutrition depends on the digestion of the food, its assimilation by the tissues, the decomposition of the tissues during the exercise of their functions, and the removal of their waste products being performed in a proper manner— in due proportion one to another. If the food is not properly digested, as in dyspepsia ; or is not properly assimilated, as in diabetes : if the tissues break up too rapidly, as in fever ; or if the waste products are not piroperly removed, as in some cases of kidney-disease, nutrition suflers. Digestion and excretion may be improved by tonics, purgatives, and diuretics ; but alteratives seem to exert their action upon assimilation and tissue-change. The digestion of food is effected by means of ferments, such as 86 ALTKEATIVES. those of the salivary glands, stomach, pancreas, etc. Some also of the changes, such as the con- Tersion of glycogen into sugar, -which the food nndergoes after absorption in the liver, and even certain so-called vital actions — such as the coagulation of the blood — are produced by a similar .agency. It is not improbable that the histolytio changes in the tissues are also effected by ferments. They do not de- pend upon oxidation, for although during health the products of tissue-decomposition are oxidised as fast as they are formed, yet under cer- tain circumstances the tissues are split up so rapidly that the products which they yield are only partially oxidized. This is seen in poisoning by antimony, arsenic, and still more markedly by phosphorus, vrhere such tissues as the muscles become decomposed, yielding nitrogenous sub- stances, such as leucin, tyrosin, or urea, and fat. The former are excreted in the urine ; while the last, instead of undergoing combustion, accumu- lates in the place formerly occupied by the mus- cular tissue, -which is accordingly said to be in a state of fatty degeneration. It is possible then, although by no means certain, that alteratives influence nutrition, either by modifying the ac- tivity of ferments, or by altering the susceptibility of the tissues to their .action. Mercurials in purgative doses, taraxacum, nitric and nitro-hydrochloric acids, probably act by modifying the digestion of the food in the upper part of the small intestine, or by affecting the . changes -which it undergoes in the liver after ab- sorption. Potash has probably an action on the muscles. Antimony, arsenic, and phosphorus especially affect the nervous and cutaneous sys- tems. Mercury has a peculiar power of breaking up newly-formed fibrinous, and particularly syphilitic deposits. Iodine, iodides, and pro- bably chlorides, act upon the lymphatic system and promote absorption. Uses. — Purgative doses of mercurials, taraxa- cum, nitric and nitro-hydrochloric acid are useful in cases of frontal headache, general malaise, and depression of spirits, associated with symptoms of so-called biliousness, or with the appearance of urates or of oxalates in the urine. Potash and colchicum are employed in the treatment of gout. Phosphorus and arsenic are used in cases of nervous debility, as well as in nervous diseases, such as neuralgia and chorea, in which antimony is also serviceable. Arsenic is also given in , diseases of the skin ; and antimony in inflammation of the mucous membrane of the bronchi. Mercury in alterative, that is, in small doses, which are absorbed into the cir- culation without purging, is used to break up newly-deposited fibrinous masses, as in iritis, pericarditis, etc., and to counteract the effect of syphilitic virus upon the soft tissues in the secondary stage of this disease. Iodine and iodides act on (.he lymphatic system, and are useful in removing glandular swellings. By stimulating the absorbent system they may also assist in the removal of the fibrinous deposits and syphiUtie growths disintegrated by the mer- cury. The iodides are sometimes given in the secondary, but are still more valuable in the taptiaiy stage of syphilis. T. LAtTDEE Bbtoiton. AMAUEOSIS. ALVEOL AB.-— Aword used in pathology as descriptive of any morbid growth which consists of small cavities or spaces {aloeoli), usually occupied by contents, and bounded by -walla formed of cells or fibres. Alveolar Cancer is the most familiar application of the term, being a synonym for Colloid Cancer. See Cancer. AMATTEOSIS {aiuaipbs, dark). — Definition. TTT^This term cannot be strictly defined. Liter- ally,,, it means an obsimrity of vision, a state of blindness, in the popular sense of the term, whereby nothing more is learnt than that the patient cannot see well enough for practical pur- poses, and is thereby unfitted for the usual occu- pations of life. Besides this, it is always tacitly understood that an external observation of the organ of vision, during the life of the patient, does not reveal any ostensible cause of blindness. It is further understood that the use of glasses is no remedy in amaurotic cases. It is rather the kind, than the degree, of blindness that is called amaurotic ; but it must be observed that lesser degrees of blindness, of the amaurotic type, are generally, vaguely and indefinitely, called amblyopia. To add to the obscurity of the subject, some -writers call some cases of moderate blindness, of the amaurotic , kind, amaurotic amilyppia ; others speak oi partial ot incomplete amaurosis. We now estimate any defect of vision with more accuracy, and record its area on a map, and its degree in figures, in comparison with a standard of ordinary normal vision. .^Jtiology. — The causes of amaurosis have been more recently specifically attributed to morbid conditions of the , percipient nervous apparatus of the eye or of vision, AU cases are excluded in which, in the present state of science, and using the ophthalmoscope, we can see any morbid condition. But very few cases are now, in the statistical tables of tho chief eye-hospitals, included under the head amau- rosis. Some few cases seem likely, at least for some time to come, to be called by this term of reproach. The ophthalmoscope has enabled us more accurately to classify a large majority of the cases formerly called amaurotic. Many new names are thus introduced to our systematic treatises on eyo diseases, whereby we gain more definite information, if only, as in some of them, e.g. ' white atrophy," we have substituted the name of a particular ophthalmoscopic sign for an indefinite symptom. At least we can speak mora accurately of the part that is or has been diseased — of the retina, or of the ocular end of the optic nerve. And, indeed, before the invention of the ophthalmoscope, the ancients, whilst professing to include only cases of disease of the percipient nervous apparatus of vision, included_ all kinds of obscure visual disorders. Mackenzie (1854) includes, besides retinitis, etc., choroiditis, and dislocated lenses ! Of the first named he says, 'It would be superfluous to consider these states separately, because we ara at present ignorant of any diagnostic signs by which, during life, the one can be discriminated from the other.' Even now, whenever the term amaurosis is had recourse to, it expresses more particularly that of which we are ignorant, and it may mean any one of so many different states that AMAUEOSIS. no anatomical charactoristica can be assigned to it. In a large majority of the cases commonly classed as those of amaurosis, it is fonnd ophthalmoscopically that there is ' white atro- phy' of the optic nerves. The 'disks' are nearly or quite bloodless; white, not pinky- white ; and the nerve-fibres going to the retinae, being more or less wasted, there is some exca- vation of the disks, perhaps so mnch that the lamina cribrosa, in one or both, is exposed to view, while the retinal vessels are somewhat diminished in size. The causes of this condition are, most commonly, intracranial tumours or other diseases which induce pressure upon the optic nerve, or lead to an extension of inflam- mation, followed by oedema or double optic neuritis (descending), these terminating in the atrophy and amaurosis. The nerve-disease is often due to syphilis. But some cases of white atrophy occur, in which there has been no pre- cedent neuritis. Of such ' tobacco amaurosis ' is an example, in which, unless smoking be given up, by an idiosyncrasy of the patient, he soon .becomes blind. But nerve-atrophy or inflam- mation should be no longer called amaurosis — they have obtained a better nomenclature. The preceding stages of the diseases causing them, ■J, as is rarely the case, unaccompanied by any definite ophthalmoscopic signs, and yet producing a considerable amount of blindness, may, for rant of better knowledge, at present be called umaurotic. Other such cases are those reported as snow-blindness ; or in which blindness has been pioduced by a lightning-flash near the eye ; a blow on the eye without other niisohief re- sulting; disuse of an eye in children, as in some neglected squint cases ; irritation from some branches of the fifth nerve (dental caries, etc.) ; anaemia after excessive losses of blood ; suppres- sion of menses ; blood-poisoning by tobacco, lead, quinine ; uraemia; and some cases of cerebral apoplexy. Embolism of the central artery of the retina occurs, but it is easy of diagnosis with the ophthalmoscope, and therefore should not be called amaurotic. The writer does not think there are any cases at long-standing blindness that show no ophthalmoscopic changes. Symptoms and. Diagnosis. — There is one symptom of amaurotic blindness, affecting both eyes, which is noteworthy, as constituting, primd facie, a general distinction between it and the other cases of blindness not of nervous origin: the gait and general aspect of the patient is peculiar — he is hesitating and hope- less-looking. He no more tries to see objects. He holds up his head ; the eyes are open and turned upwards, as eyes not in use (in sleep) always are, or because the patient has felt the heat of the sun from overhead, and has last enjoyed sensation of light, whence he knows it comes, from above. Hia feels his way with his feet, and his hands are extended before him. He does not look towards you, or at anything in particular. But amaurosis does not by any means itnply a similar state of vision in both eyes, nor that the blindness is to be taken in the ophthalmological sense, i.e. wanting perception of light. It would be well if any less degree of imperfection of vision, without evident cause, AMBLYOPIA. 87 might be called arMyopie, but the two eyes must be considered separately. To diagnose the absence or presence of a power of perception of light, certain important precautions must be taken, as almost all patients who are abso- lutely blind will declare, and probabl;y be- lieve, Uiat they still can see light, i.e. objective light. The patient should be placed opposite to a bright light, such as a gas-lamp, and near to it, but not so near that he can feel the heat of it ; the light is then turned up and down, and it is fully exposed and obscured, and the patient is asked many times, in quick succession, if he sees light or not. The light should be left burning and exposed, or not, during several of the suc- cessive queries, so as to do away with any doubt. The word of the patient untested is quiteinad- missible. Any ether blindness than this of abso- lute amaurosis, or originating in any other diseases than those of the percipient nervous apparatus of the eye, is never so great as to prevent the perception of light. If the patient can see light from darkness, test whether he can see shadows of some small object — of the hand, or of one finger only, passed between him and the burning light, or the light of the window only. • If he can see to count fingers, his blind- ness is insufficient to indicate what is called amaurosis. Another point in the diagnosis of amaurosis is that, ophthalmoscopically, the appearance of the fundus of the eye is normal, or such as, independent of errors of refrac- tion, we find in other cases compatible with standard vision, or at least with a fair amount of useful vision. This will allow of aconsiderable latitude, and will not include any slight or imagi- nary hyperaemia or anaemia of the optic disk, any physiological excavations of the same, or congenital opacities of the retina, etc. The pupil of the affected eye is, if the other be perfectly ex- cluded from light or vision, nearly always dilated, to almost the greatest extent, though atropine dilates it yet more fully, and it is fixed, being insensible to light; Peognosis.^ — After a due consideration of the cases thus classed together — and they are very unlike in fact, and often very obscure — we may say generally, that if the blindness be of one eye only, sudden and recent, the prognosis is hopeful ; but if both eyes are affected, and' the disease, whatever it may be, is of steady progress and of long standing, it is verr serious. The cases of amaurosis are very rare indeed in which vision is perfectly restored ; most of them end fatally to vision, or would so end but , that the disease is sooner fatal to life. Treatment.— This must necessarily be varied according to the cause of the amaiirotie condi- tion. Por instance, if there is intra-cranial disease, treatment directed thereto must be fol- lowed out; and should there be indications of syphilis, iodide of potassium and small doses of mercury must be given for some time. When amaurosis depends on any injurious habit, such as smoking, this must be relinquished. Large doses of strychnine and iron are useful in ad- vanced white atrophy. J. P. Stebatfeild. AMBLYOPIA (a/.;8A{ij, blunt, and H sight). — Obscurity of vision. See Amaueosis. 38 AMBULATOEY. AMBUIiATOBT {amhulwre, to walk).— A term applied to latent typhoid feyer, signifying that the patient is able to walk about during the attack. See Typhoid Feteb. AMEWOKBHCBA (4, priv. ; A^V. a month ; and ^e'fti, I flo-w).— Absence of the menstrual flow during any portion of the period of life when it ought to be present. See Menstruation, Dis- orders of. AMEWOBBHCEAL IBTSAliriTT. See Insanity. AMENTIA (a, priv., and jiivos, the mind). ^An obsolete term for Dementia. See De- mentia. AMNESIA (o, priv., and uvriais, memory). See Aphasia. AMPHOBIC— A peculiar hollow metallic sound, elicited occasionally by percussion, but more commonly heard in auscultation. Am- phoric breath-sound resembles that produced by blowing into a large empty glass or metallic vessel {amphora). See Physical Examination. AMTODAIiITIS (fimygdale, the tonsils). — A synonym for inflammation of the tonsils. See Tonsils, Diseases of. AMYLOID DISEASE {iiuiKov, starch). ■ — The name given by Virchow to Albuminoid Disease, from the belief that the material charac- teristic of this morbid condition is of the nature of starch or cellulose. See Albuminoid Disease. ATirar.TWTA (4, priv., and ot/uo, blood). — SYNON. : Spanismia ; Sychrtsmia ; Oligemia; A- globulism, Pr. Anemie. Ger. Anamie ; JBlmtar- muth. Definition. — Deficiency of blood in quantity, either general or local ; also, deficiency of the most important constituents of blood, particu- larly albuminous substances and red corpuscles. This definition is purely pathological', and the condition thus expressed presents many varieties. Anaemia in the widest sense of the term including Oligsemia, Oligocythsemia, Hydrsemia, and Spanse- mia, as well as Clilorosis. (See Chloeosis, Hyde2E- mia, Spanjemia, Oligocythjemia,. and Blood, Morbid Conditions of.) From the clinical point of view, Anaemia is a condition of system in which impoverishment of the blood, whether from want or from waste, is associated with symptoms of imperfect discharge of the vital functions. .ffiTioi.o(}Y. — ^The causes of anaemia are gene- rally multiple and complex. First, the supply of blood to the body may be insufficient, and that from a variety of causes, of whidh the chief are : — derangements of alimentation, including in- sufficient food, and morbid states of the lymphatic and blood-glands ; such defective hygienic con- ditions affecting the formation and nutrition of the blood as want of light, air, and muscular exercise ; prolonged exposure to the influence of certain poisons, as lead, mercury, and malaria ; and, lastly, interference with the free circulation of. the blood by cardiac or vascular disease, such as valvular disease or dilatation of the heart and aneurism of the aorta. Secondly, the con- evmption of blood may be increased by haemor- rhiige ; by profuse discharges, such as suppura- AN.EMIA. tion, catarrh, and albuminuria; by rapid growth and development ; by frequent pregnancy.and superlactation ; by excessive muscular exertion ; and by the presence of pyrexia,or of new growths, which rob the system of nutritive material. In a third group of cases of anaemia both thff supply and the consumption are at fault. Thus derangement of the organs and of the whole process of sanguification is frequently associated with profuse discharges from various parts ; and in malignant diseases and the 'chronic constitu- tional diseases,' such as syphilis, tuberculosis, Bright's disease, albuminoid disease, Addison]s disease, and others, the cause of the anaemia is extremely complex. But the majority of the cases of anaemia that are regarded and treated as such fall into the class to which the name of idiopathic has been applied. In such cases the anaemic condition is due, not to any disease so- caUed, but to disturbance of nutrition generally, that is of the healthy relation between the demands of the system and the supply of nu- trient material. This condition occurs chiefly in children and young women, at the period of bodily growth and of the development and early activity of the sexual functions ; and when, as so frequently and unfortunately happens, the air, light, food, occupation, and moral rela- tions of the individual are all more or less un- healthy. Anatomical Chaeactees. — The blood suffers three principal changes in declared anaemia, namely, (1) deficiency in amount (Oligaemia) ; (2) deficiency in red corpuscles or haemoglobin (Oli- gocythaemia, Aglobulism) ; and (3) deficiency in albuminous constituents (Hypalbuminosis). Of these Oligsemia is the simplest, and perhaps never occurs alone ; it is speedily complicated with Aglobulism, which is a very early and common, aa well as the most obstinate, change in the blood. Hypalbuminosis is the most advanced and perhaps the most serious alteration of the three. ("See Blood, Morbid Conditions of.) The blood is scanty and pale, and has a diminished specific gravity; and coagulates slowly and loosely, or in aggravated cases not at all, settling into three layers — consisting respectively of red corpuscles, white corpuscles, and plasma. The body pre- sents certain changes directly due to the state of the blood. Whether the anaemia be local or general, the corresponding parts are blanched ancl ' bloodless.' The cells of the tissues become atrophied and degenerate, in consequence of, and in proportion to, the interference with their plastic and functional activity respectively; and the so-called 'anaemic' form of fatty heart, liver, kidneys, and other organs, is the result. If death occur suddenly from acute anaemia the heart is found empty and contracted. Pathology. — When the volume of blood in the body has been reduced by repeated small hae- morrhages, the phenomena that supervene, while they express the want of blood as a whole, and of its several constituents, are chiefly referable td the loss of two of these constituents — the albuminous substances and the red corpuscles or haemoglobin — that is, of the oxidisable and the oxidising materials. The pathology of hypalbu- minosis and aglobulism is fully discussed in the article on diseases of the blood, and need not be ANJEMIA. 8(t ropeatpd here. The same effects will be pro- duced ty a drain of the liquid part only of the blood, or by poverty of the blood from any of the causes enumerated above, whether of the nature of waste or of want ; inasmuch as loss of plasma speedily affects the nutrition of the red corpuscles. These phenomena constitute the symptoms of the ansemio condition whatever may be its cause ; their relative prominence naturally varying according to an immense number of cir- cumstances. Symptoms.— The subjects of antemiaare usually girls and young women. Their general appear- unce, which is striking, is one of pallor, debility, ind variable loss of feminine fulness. The visible parts of the surface are pallid, often with a tinga of dusky brown on the eyelids and the backs of the hands ; the clearness of the complexion varies with the normal pig- mentation of the body ; the skin is soft, satiny, and rather loose. The mucous surfaces also are blanched ; the sclerotic is pearly blue. The loss of flesh maybe moderate, or it may be considerable. The extremities are cold, and the legs and lower eyelids are often oedematous. Bodily strength is reduced; muscular force is diminished, while myalgia is common ; an air of languor and want of vigour pervades the whole demeanour ; and the patient is.sleepy, dull, and depressed. The subject of anaemia generally complains of weakness, va- rious pains about the body and head, and marked shortness of breath on the least exertion. The last symptom is unaccompanied by other evi- dence of respiratory derangement ; in character the breathing is regular, and short or even pant- ing. The symptoms referable to the circulation consist chiefly of palpitation on exertion; a tendency to faint ; and pain or even distress over the cardiac region. The impulse ia variable ; the first sound is either hollow or murmurish, or con- verted into a murmur at the base, and frequently even over the whole prsecordium ; the diastolic sound is sharp generally. Over the manu- brium and in the cervical vessels a murmur followed by a sharp sound is commonly audible, and tlierewith a venous , hum. The cervical vessels may throb ; the radial pulse is small, soft, weak, and of variable but usually increased fre- quency and suddenness. There is a tendency to haemorrhages, especially epistaxisj and petecbiae are occasionally observed. The digestive system is markedly affected, as shown by loss or perversion of appetite ; an ansemio, often bare, but variable tongue ; dyspepsia, nausea, and sick- ness after meals or on rising; and constipation, which is present in the majority of cases and is frequently prolonged and severe. The menstrual functions are almost always deranged ; amenor- rhcea is common in some form ; menorrhagia is rare (except as a cause of anaemia) ; dysmenor- rhoea is frequently associated ; and leucorrhcna is the rule. The urine is usually abundant and pale, but varies greatly. Headache and other cerebral symptoms are common. Blood drawn ftom the &jger presents agtobulism. SeelLsMAOYTOMETEE. The leading phenomena of acute anaemia are those of syncope, or suspended animation from feilure of the circulation, and are described under Chat title. CouasB AND Tebminations. — The course of anaemia in this form is essentially slow and pro- gressive, unless it is checked ; the duratton is perfectly indefinite. The course of the symp- tomatic form will naturally vary with its cause. Idiopathic anaemia rarely terminates fatally ; and, when it does so, the event may be referred with few exceptions to some complication. Ocai- sionally, however, it proceeds steadily to death (see PBOGnEssrvE PrniNicious Anjemia, below). Intercurrent diseases may be expected to bo severe in an anaemic condition, in proportion to its degree. DiAONOsis. — Anaemia is generally recognised with the greatest ease, and the chief question of diagnosis relates to its cause. The first point to be determined, therefore, is whether it is not symptomatic of some more grave state, such as tuberculosis, syphilis, albuminoid disease, or some other of the many possible causes of poverty of blood. Having settled that the anaemia if idiopathic, we must next exclude two diseases with which it may be , confounded, namely, chlorosis and leukaemia. Chlorosis, in which the plasma is not considered to be altered, and which possesses otherwise a special pathology, is ex pressed by the yellow tint of skin, by the absence of wasting and of dropsy, as well as by other features {see Chlobosis.) Leukaemia is recog- nised by examination of the blood, spleen, and lymphatic glands. The starting-point of the blood-change in cases of idiopathic anaemia, can only be discovered by careful investigation of all the facts of the case. Peoonosis. — The prognosis of anaemia is favourable as regards life. In simple anaemia from loss of blood, the patient may be assured of speedy and complete recovery. In idiopathic anaemia, however, this promise can be given.only when the cause can be removed or avoided. Under favourable circumstances and sound treat- ment, improvement will begin almost immedi- ately ; and health should be restored after a few weeks or months. Tkeatment. — The treatment of anaemia, when it is symptomatic of some more grave con- dition, such as Bright's disease or phthisis, does not require notice here. When blood has been lost in serious quantity, without other Injury of consequence, it will be naturally restored if suffi- cient time but be given and interference other- wise avoided. Attention to the ordinary rules of health, abundance of food and air, and moderate exercise, will surely, if slowly, restore the patient, without the administration of a single drug. Even in this case, however, treatment may be of great service, by arresting, if necessary, the cause of the anaemia, such as menorrhagia or epistaxis ; and by assisting nature, if the condition should threaten at any time to become intensified by its own effects. But before the blood can be restored in the large and ill-defined group of cases known as idiopathic anaemia, the unhealthy influences under which the patient is placed, and the functional and other derangements, which are usually accountable for the imperfect sanguification, must be dis- covered and corrected. "Where the aetiology is complex, treatment must be equally general, and the whole system of life will have to be reformed. On the other hand, in the rapidly growing child 40 AISMMIA. and youth, and still more in girls at puberty, the great demand for nutritive material must be duly considered and every obstacle to its supply re- moved. When other than direct discharges are draining the blood they must be checked. Lac- tation may have to be forbidden ; and leucorrhoea and spermatorrhoea ■vpill sometimes demand local treatment. The removal of the cause being thus made the first element in treatment, means must next be adopted for the restoration of the blood. But before this can be accomplished, it will be neces- sary to bring the alimentary tract and the organs of sanguification into a healthy state. Dyspepsia and constipation require immediate treatment; and for this purpose simple alkaline and bitter stomachics with rhubarb, and free purgation by ordinary means, followed by a course of aloes and iron pill at night, are the best. The food must be carefully ordered, so that it shall not only supply the albuminous elements that are specially deficient in the blood, but be retained and ab- sorbed ; it must therefore be at once nourishing and digestible, and be taken in email quantities at frequent intervals. The patient must not be allowed to yield to the disgust that she may have for meat. The process of sanguification may be success- fully assisted by means of drugs. Iron is the sovereign remedy for aglobulism ; and, practically speaking, it speedily becomes a question in the treatment of a ease of anaemia in what form iron is to be given. The compound iron mixture.of the pharmacopoeia answers more frequently than any other ; but, on the one hand, when there is much constipation, the protosulphate with pur- gative saline sulphates will be more suitable for a time ; and, on the other hand, when there is a tendency to discharges, the per-salts with bitters will better answer the purpose. The combinations of iron with quiuia or strychnia, should be given in cases where less marked ansemia occurs in older subjects with nervous depression and general want of vigour. In special cases the ferrum redactum, saccharated carbonate, vinum ferri, or the French dragies fer- rugineuses at meal times may be ordered. Cod-liver oil may sometimes be prescribed with success. Other symptoms must be treated on ordinary ' principles. Uterine complaints demand special attention ; and bromides, ergot, opium, and other sedatives and astringents are indicated where excitement and excessive discharge are present. While these dietetic and medicinal measures are being carried out, it is impossible to insist :too strongly upon attention to bodily and mental hygiene. In a large number of cases change of air fulfils all the necessary conditions, and it is generally to be recommended. Above all, time is an essential element in the cure ; and rest is scarcely less so. . A frequent change in the form of the medicinal remedies, is also advisable. Progressive Pernicious Aneemia. — A peculiar form of anaemia has long been known, but has lately attracted special attention, and is variously designated as pemicietta^ malig- nant, idiopathic, and progressive, on account of the Intensity of the symptoms, the ob- Dcnrily of its pathology, and the frequency with ANJESTHETICS. which it advances to a fatal termination, This disease may occur in both sexes, but has been most frequently observed in middle-aged, pregnant wo- men; it presents no special post-mortem appear- ances ; and it cannot be referred to anyreasonable cause. The aymptom are those of excessive anae mia,as described above; but gastric disturbance and general haemorrhages are relatively promi- nent, and, in some cases, irregular attacks of pyrexia occur. The blood during life is said to differ from that found in ordinary anaemia, by con- taining an unusual amount of ill-shaped red cor- puscles and granular matter. The course of the disease is steadilytowards death, in which itgene- rally terminates. The pathology of progressive pernicious anaemia is obscure. It is believed by some to be but the advanced stage of or- dinary anasmia, which attracts attention by its resistance to treatment, and it^ fatal ter- mination. The appearance of the blood would seem to indicate excessive destruction, rather than insuficient supply of the important elements, as the essential cause of the morbid condition ; but there is probably dea:angement in both directions. The prognosis is as unfavourable as possible. T?reatment must be ordered on general principles : transfusion has been frequently t);ied, but with- out success. J. Mitchell Bbucb, Air.a!MIA liYMPHATICA.— A form of Anaemia which is associated with a peculiar af- fection of the Lymphatic ISystem. See Hodg- kin's Disease. AN-fflSTHESIA (4, priv., anAaurBdvoiuu, I feel). — ^Anaesthesia literally means absence or loss of sensation, which may be general or local. The word is, however, more especially employed to signify loss of tactile sensibility, as distin- guished from insensibility to pain or Analgesia. It is further used to indicate the condition in- duced by the action of Ansesthetics- upon the system. See Sensation, Disorders of. Air.fflSTHETICS. — Definition. The name given to a series of agents which are employed for the prevention of pain, but more especially applied to those used in surgical practice. HisTOET. — The idea of annulling pain in sur- gical operations is a very old one. Compression of the nerves and blood-vessels, and. the inhala- tion of the vapour of mixtures containing car- bonic anhydride were practised at an early date. In the sixteenth centuiy ether was probably the active ingredient of a volatile anaesthetic de- scribed by Porta. The use of anaesthetics was, however, but little understood and rarely prac- tised. Even the suggestion of Sir Humphry Dayyj that nitrous oxide should be used in minor operations not attended with loss of blood, was of little practical value, on account of the inefacient apparatus then available. In ] 845 Hora,ce Wells inhaled laughing gas so successfully that he may be said to have introduced the, practice ; but he appears to have so often failed to produce the desired effect that this agent fell into disuse on the introduotionof ether in 1846 by Morton, after some communication on its properties from a chemist named Jackson. In 1847 chloroform was used by Simpson, and quickly superseded ether almost all over Europe. At the present ANESTHETICS. 41 time the comparative safety of ether has caused this ansesthetio again to be preferred by many eurgeons in this country. Endmeeation. — The three agents just men- tioned, namely, nitrous oxide, ether, and chloro- form, are those chiefly in use, and they have each advantages in particular cases. Experiments made irith other agents, such as amylene, tetrachloride of carbon, eQiidenedichloride, and bichloride of methylene, have not shown that they possess safficient advantages to counterbalance the defect of requiring special management in their ad- ministration. This list of ansesthetics might be still fiurther increased, for in order to produce insensibility it is only necessary to reduce the supply of arterialised blood to the nervous centres, or to introduce into the blood a sub- stance ■whioh deprives it of its power of oxygen- ating the tissues. Modes of XJsb, — Ausesthesia may be produced for surgical purposes: — 1. by benumbing the part to be operated on by means of cold ; 2. by intercepting its nervous communication ; 3. by arresting tiie activity of the nervous centres concerned in sensation. Thus ansesthetics may be local or gmeral in their action. Iiocal Aneesthesia may be induced by cold. The most convenient plan is to blow a jet of anhydrous ether spray upon the part, as sug- gested by Dr. Bichardson, and thus to freeze it. The surface to be frozen should be dry, and hence the difficulty of freezing the gum of the lower jaw, on account of the saliva. A mixture of equal parts of pounded ice and common salt contained m a bag of muslin is eflfective, but less easily applied. This plan is adapted for opening ab- scesses and boils, and for the extraction of a few teeth ; but the process both of congelation and of thaw is painful. Chloroform applied locally is said to cause numbness, but- it isi very little used except inside the miouth, and then it owes its soothing effects to the quantity of chloroform vapour which is inhaled. Compression of nerve trunks for inducing ansesthesia is never prac- tised at the present day, . General Ajieesthesia is at present rarely obtained in any other way than by inhalation, although successful attempts have been made to induce the condition by subcutaneous and in- travenous injection of chloral or morphia. Subjects fob Anesthetics. — We may say generally that any person fit for a severe ope- ration is a fit subject for an anaesthetic, but no one is so free from danger that care in watching its effects can be dispensed with: The cases requiring the greatest vigilance are not the young and deli- cate, for whom a small dose suffices, but the strong, who inhale deeply and struggle much. Ether is probably better for those suspected of fatty de- generation of the heart, although as a rule such cases are eminently satisfactory under chloro- form. Many of the deaths under chloroform have occurred in intemperate drinkers, and the presence of alcohol in the system undoubtedly intensifies its effect. Pkeoautions, — Before commencing inhalation the following particulars should be attended to. The patient must not have recently taken a full meal ; he should lie comfortably, in a horizontal position if possible, unless when gas or ether is given for a short operation j and the dress should not be tight. When the administration is begun, he should be encouraged to breathe regularly and freely. The pulse as well as the respiration must be watched. If the vapour excites either swal- lowing or coughing, it is more pungent than is requisite, and its strength should be diminished. Most patients are at first afraid of breathing, and some hold their breath for half a minute. Tlie vapour should not be removed on this account, but care should be taken, by holding the inhaling apparatus farther off, to prevent the vapour becoming too strong iu the interval. After volition has been abolished, any pause in the breathing should be noted, and more or less fresh air given. Further directions will be given in describing the anaesthetics specially. . • Special Anjbsthktics. — Frotoxide of Nitrogen, Nitrous Oxide, or Laughing Gas. This agent is now prepared wholesale, and sold condensed into a liquid in strong iron bottles. Thegas, whether supplied thus or from u gasometer, should be inhaled from a bag having such a free com- munication with the face that it will readily be supplied even in panting respiration. A long tube, however large, is objectionable, as the gas is less mobile than common air. The special aim in giving gas should at first be to exclude air, and to exchange the atmosphere within the air-passages and lungs for one of pure gas. The patient should not merely be told to breathe slowly and deeply, but be shown how to do so, aboat fifteen times in a minute. The in- spiration should not be jerking, and the expira- tion should be complete. It is a special merit of laughing gas that no harm can come of inhal- ing too freely at first. The gas-bag must be kept filled either by pressure on the gasometer, or by turning the screw tap of the gas bottle. This may be done by the hand of an assistant, or more conveniently with the foot of the admi- nistrator, by means of a contrivance invented by Mr. Braine, in which the gas-bottle is placed hori- zontally upon rollers and moved by the foot whilst the head of the screw is fixed; The writer's plan is to iix the bottle vertically and turn the screw by pressing the foot against an iron plate with spikes on its upper surface, and a square hole fitting the tap on its lower surface. It is imperative that the face-piece or mouth- piece should fit aocurately, and the air-pad is almost essential to effect this in a great many cases. It should be warmed if the indiarubber is stiff After five or six good respirations there is no need of supplying fresh gas with each in- spiration. The expiring valve should be kept closed, and the inspiring valve opened. Care must always be taken that the supply of gas is suffi- cient to replace any that is lost by absorption into the blood or by leakage. This is more easily effected if the gas-bag is made of thin indiarub- ber, so as to distend- easily and contract gently with the movement of breathing. It should be sufficiently filled, so that if the mouth-piece does not fit, the gas would escape instead of air entering and becoming mixed with it. Lividity of the skin will not help us to know when the patient is fully under the influence of the gas, neither will insensitiveness of the eyelids, nor yet the state of the pupils. The breaking ■12 ANJESTHETICS. should become stertorous or icterrapted, or the pulse very feeble, or conyulsive twitchings should occur, before the face-piece is removed. A little air may beiadmitted by raising the face-pieoe,Jf the operation is not upoii the face, and by doing so every fourth or fifth respiration ansesthesia may be kept up for several minutes. The effect of a single full inspiration may be to bring the patient into a state of excitement, and the Continuance of the gas without air brings on conVillsive move- ments, so that it is not well adapted for any operation lasting as much as five minutes, and requiring steadiness. Patients are sometimes so unsteady that it is found to be almost impossible to make the face-piece fit. In such eases the best plan is to cover the patient's eyes and let hiin breathe air, merely preventing him from rising from the chair or bed, and not speaking till he is conscious, and as soon as he becomes so to recommence the inhaling as if nothing had happened. A violent patient often' becomes perfectly rational in less than two minutes. Sickness and ■ headache ought not to result from the inhalation of gas, but if the use of it is prolonged, or if the patient is kept for several minutes in a semi-conscious state, breathing a little air with the gas, both these symptoms may occur. The recumbent posture, qnifet, and warmth to the feet, constitute all that is likely to be required in the way of treatment. Ether, Sulphurio Ether, Ethylio Ether, Vinic Ether, or Oxide of Ethyl, was first used for anses- thetio purposes in 1846. Before its use was well understood in England chloroform was brought forward as a more convenient agent, and much less unpleasant to the patient. Ether is' less liable to become dangerous to life, as it does not under ordinary circumstances depress the action of the heart. If ether be given from a towel or hollow sponge, the best Kind is the Mther Furus of the Pharma- copojia, of sp. gr. -720 ; but the ether of sp. gr. 735, which contains a little water, answers very well if the towel or napkin is arranged so as to form a large cone, thus lessening the access of fresh air. The disadvantage of using the latter kind is that the moisture of the patient's breath condenses upon the surface made cold by the evaporating ether, and diminishes its volatility. When pure ether is used, a certain amount of condensed aqueous vapour is taken up before it reaches the density -TSS. In all inhalers where an arrangement is made for preventing the ether from becbming too cold, the washed ether 735 may be used, and will be fftund cheaper. Not only is it sold at a lower price, but it is much easier to keep from escaping through cork or stopper. Although it is not difficult to destroy dogs sud- denly -with ether, it is believed by many writers on the subject that in man it can only prove fatal by causing asphyxia, and that the signs of this condition are so easily seen and remedied that practically this anaesthetic is quite safe. The ■writer is not of this opinion, belie'ving that some- times -when narcosis is far advanced, the glottis will allow ether vapour to pass of sufficieiit strength to stop the heart. Such eases, however, are very rare indeed. Ether is extensively adminis- tered by pouring an ounce at a time upon a very large cup-shaped sponge, which, if cold from previous use, is dipped into hot water and squeezed as dry as possible. • It is to' be expected that the patient will resist breathing when this is held over his face, but after a minute's struggling hei becomes unconscious, and easy to manage. Compared with giving ether timidly,' so as to let the patient remain delirious for several minutes, this may be a good plan ; but there is no necessity for giving the ether so strbhgfly if we diminish the' acoess of fresh air. _ The ad- ministration of nitrous oxide from which air is at first excluded; and afterwards admitted very sparingly, has taught us how slight the after- effects are from the asphyxia so induced. Cones of leather or pasteboard lined with felt, and having a small opening at the apex, are better than sponges ; but they should be larger. They may be made more effective and economical by placing a thin india-rubber bag over the apex of the cone, so that more of the expired atmosphere may be breathed again. Morgan's inhaler is very efficient. The ether is pbured into a tin chamber &a large as a hat, con- taining sponge. This in covered by a sort of diaphragm, which rises and falls with respiration as the patient breathes into and out of it by means of a tube and face-piece. There are no valves. Ansesthesia results partly from asphj'xia, and' partly from the action of the ether. The amount breathed depends on its temperature, and on the freedom of respiration. If the respiratory movements are slight, as in young children, or in persons suffering from emphysema, the amount of etheir supplied is apt to be too small. Ormsby's inhaler is an improvement upon it, The sponge for ether is contained in a cage near the face-piece. An excellent inhaler for hospital purposes and for prolonged operations is sold by Mr. Hawkes- ley. The ether-vessel is kept in a water-bath. There are valves which allow air to pass over the ether, but prevent its return, and the ap- paratus has an arrangement for lessening the odour of ether in the room, consisting of a tube leading to the floor, which carries off the expired air and ether. With the view of regulating the strength of the ether vapour, the -writer has contrived the folio-wing apparatus, which is made by Mayer and Meltzer. It consists of an oval india-rubber bag fifteen inches long, at one end connected with the face-piece, at the other with the ether-vessel. Within the bag is a flexible tube alsoleading from the face-piece to the ether vessel. By turning a regulator the patient is made to breathe into the bag either directly or indirectly through the tube and ether vessel, or pdrtly one way and partly the other. The more the regulator is turned towards the letter E, the more ether vapour he takes. By turning it back again the amount of vapour is diminished. The ether-vessel contains a reservoir of water, which prevents the ether becoming too cold from evaporation. It is filled -with ether up to a mart on the vessel. A thermo- meter in connection shows the temperature of the ether. _ The vessel should be just dipped into a basin of warm water and gently rotated till the thermometer reaches from 65° to 70°. ANAESTHETICS. 13 Wheu nseniitjiis vessel should bo suspended by a strap from the neck of the admiidstrator. At fiist the regulator aUows the passage from the faee-piece into the bag to remain open, and the bag should be filled by pressing the faoe-pieee more fcmly against the faceduringexpiration than inspiration. By degrees the regulator is turned towards letter E, and thus the -way to the inner tube is opened, and the air breathed through it carries ether vapour from the vessel into the dis- tal end of the bag. "When the regulator allows half the inspired air to pass tlirough the ether, the vapour is strong enough to induce sleep in two minutes, usually without exciting cough. As the act of swallowing is excited by a smaller quantity of ether than that of coughing, it should be watched for, and the regulator very slightly turned back should it occur. This same apparatus may be used for giving laughing-gas, all communication with the ether- vessel being cut off by turning a stopcock, and by attaching the tube leading from the gas- bottle to a mount near the bag. By far the least unpleasant and the quickest way of preparing a patient for a surgical operation is to use gas and ether combined ; the change from gas to ether being made by turning the regulator above described as soon as the patient is siAciently under the influence of gas to disregard the flavour of ether. The supply, of gas should be stopped as soon as the ether is introduced ; but if subsequently the patient is allowed to become conscious, the gas may be given freely as at first, in order to make him sleep again. The writer finds less sickness and more rapid recovery from the unpleasant taste of ether than when the latter is given alone. The chief dif&culty is to prevent the unsteadiness of the patient, resulting from the panting character of the breathing. To lessen this the ether must be given as strong as possible without producing irritation of the throat, and the operator should wait until the influence of the ether has increased to the production of deep stertor. Air being then admitted with every fourth or fifth inspiration, the breathing soon be- comes as reguleur as it is under ether when given in any other way. On recovering from the inhalation of ether patients are often in a state of intoxication for a period corresponding to the time and extent of the etherization. The eyes should be covered, but the mouth and nose left free ; and the room should be kept quiet, with a brisk fire, and the window more or less open. See Appendix. Chloroform was introduced by Simpson in 1 847. It should not be made from methylated spirit,, and, when a drachm is poured upon blotting paper, it should evaporate without leaving, an unpleasant odour. It is the most convenient of all anaesthetics, and the most easy to admi- nister. Unfortunately, when given beyond a certain strength, it has a tendency to produce cardiac ayncope, and it is not improbable that some persons are particularly liable to be so affected. Some authorities think it desirable to give alcoholic stimulants before administering chloro- form; otliers partially narcotize the patient with morphia or chloral. No doubt these agents Assist the action of the chloroform, but if from any accident an excess of chloroform should be given, they interfere with the means of recovery, and for this reason are not to be recommended. There is less objection to the inhalation of a mix- ture of chloroform and ether, or of these agents with alcohol ; but such mixtures, if kept for some length of time, alter their relative proportions, owing to the escape of the more volatile in- gredients. Even tiie change from the adminis tration of chloroform to that of ether, if made suddenly, is not free from danger, for, when a person is partially under the influence of chloro- form, the glottis allows a high percentage of ether to pass ;. and, if the lung-circulation be slow, as is likely to be the case, the blood may be so highly charged with ether as to depress rather than stimulate the heart. Chloroform, therefore, should be given gradu- ally. The object should be to keep down the proportion of chloroform-vapour rather than to give abundance of fresh air. In preparing for au operation requiring perfect stUlness, six to eight minutes should be allowed for the process. Sponges or lint saturated with chloroform, and held close to the mouth, are dangerous, from the possibility of liquid chloroform falling on the lips or into the mouth. In midwifery practice a piece of linen or blotting paper sprinkled with chloroform and placed at the bottom of a tumbler is a convenient plan of administration, care being taken to prevent any liquid chloro- form from settling at the bottom. In general surgery a handkerchief or towel may be folded into a small cone, open at the apex, into which not more than a drachm should be poured at flrst, and fifteen minims at a time afterwards. A better plan is to roll and tie a piece of lint into a compress the size of a walnut. A drachm to a drachm and a-half of chlo- roform should be poured upon this, which is to be held about an inch in front of the patient's upper lip, the hand and compress being covered with a towel, which should gradually be drawn over the patient's face. This plan gives considerable com- mand over the supply of chloroform, for, when the chloroform, having cooled by evaporation, is given off too slowly, the vapour can be increased by warming the compress in the palm of the hand. When it is becoming dry it ceases to feel cold, and warning is thus given that fresh chloroform is needed. This should be supplied half a drachm at a time. In doing this the towel should still be left over the face of the patient in order to keep him breathing a slightly chloroformed atmosphere. The movement of swallowing should be looked for, and regarded as evidence that the vapour is stronger than is necessary. If any sound like hiccough indicates laryngeal obstrnction, the chloroform and towel should be removed, and, if the sound continue, the chin should be raised as much as possible from the sternum. Laryngeal obstruction arises from two main causes, viz., spasm of the glottis, and falling down of the epiglottis. The first is excited by the pungency of the vapour, and also by reflex action when certain nerves are injiired, notably when a ligature is tightened upon a pile. The epiglottis covers the larynx every time we swallow, but the muscles coming from the chin raise it again directly. In deep narcosis these muscles are sluggish, and cannot act thus if the position of the chin places them at a disadvantage. If raising the chin fail to open the air-passage, the tongue must be pulled forward. In doing this the head should _b6 kept back. Depressing the chin renders a partial obstruction complete. A laryngeal sound in- dicating obstruction is of little consequence if the pulse is good, since, although the breathing be imperfect, sufficient iTesh air continues to be breathed ; but if the pulse flags, or if it appears that the amount of chloroform in the air-pas- sages is excessive, not a moment should be lost in seizing the tongue with forceps. When a patient is delirious and struggling, extra core must be taken that the chloroform be not too strong, because he inhales deeply, carry- ing the vapour almost to the air-cells of the lungs, and, when he next closes the glottis and strains, the pressure of the air and vapour within the lungs is increased, and the chloroform enters the blood very quickly. The compress should be held at least two inches off the mouth, although the- towel may still cover the face. Directly any stertorous noise is heard, a breath or two of fresh air should be allowed, and no more chloroform given till the pulse beats well and the respiration is free. Skinner's apparatus — a cap of ' domette' flannel stretched over a frame — is a much better appar: ratus than a towel ; but its virtue is simplicity, and it has little pretension to exactitude. Snow's apparatus is very efficient, portable, and econo- mical. The addition of a water-jacket to equal- ize the temperature was a great improvement ; but it should be provided with a thermo- meter. The safest and least unpleasant mode of giving chloroform is by means of the apparatus fitted with a large bag of air containing not more than thirty-three minims of chloroform in a thousand inches of air. The apparatus is, how- ever, too complex to be generally adopted, aud the writer hopes shortly to be able to introduce a modification of it which will be more easily used. The advantage of more precise measure- ment of the strength of chloroform-vapour than is afforded by towels or napkins will appear when we consider the several circumstances that alter it when so given. The strength of vapour given off from a known quantity of chloroform is influenced by : — 1. The extent of surface of chloroform. 2. The temperature of the chloroform, which is constantly diangingi 3. The temperattire of the air of the room, of the patient's face, and of the administrator's hand. 4. The distance at which the chloroform is heldfrom the patient's feee. 5. The rapidity of the current of air, 6. The height of the barometer. Moreover, when the chloroform-mixture is of known strength, its effect is increased by high barometrical pressure; by low temperature of the blood ; by deep or quick respiration, and especially by muscular efforts when the glottis is closed ; and by slow movement of the blood through the lungs. On the other hand, it is lessened .by low baro- metrical pressure ; by high temperature of blood ; ANjESTHETICS. by superficial or slow respiration ; and by rapid circulation through the lungs. Under ordinary circumstances danger from these causes is easily averted with moderate earo, for they do not often concur to produce the same effect ; but if a patient, fatigued with struggling, takes a very deep breath just as fresh chloroform has been poured upon the towel, and then closes his glottis and makes another struggle — the barometer being high at the same time — it is evident that blood unduly sharged with chloroform will gain access into tho coronary arteries, and depress the cardiac ganglia. Death has occurred so rapidly under these cir- cumstances, that it has been thought to be the result of shock from the operation. Chloroform lessens, if it does not entirely prevent, the shock of an operation, but it is to be feared that if chloroform be given freely for this purpose, a dangerous amount of it will be administered. If a severe operation is about to be performed, the chloroform should be given in the same gradual manner as in a slighter one, but con- tinued to the point of fixing the pupils and pro- ducing stertorous breathing ; aud, when the chief shock is expected, two or three breaths of pure air should be admitted, so that, if the pulse fail, there may not be an excessive amount of chloro- form-vapour in the lungs. Compounda of Chloroform. — Under this head comes Sichloride of Methylene, which contains a variable quantity of chloroform. ■ Its che- mical characters and physiological effects are very similar to those of a mixture of chloroform, ether, and alcohol. It narcotizes quickly,' but not safely ; and, as the amount of chloroform in it is not always uniform, it is better to mix, in small quantities at a time, one part of alcohol, two of chloroform, and three of ether, and to keep the bottle so well corked thai the ether is not likely to evaporate and leave chloroform in excess. The word ACE fixes the proportions in one's memory. A mixture of one part of chloroform with four of ether is convenient for a brief operation, as this produces much less excitement than ether alone. On the whole the writer objects to keej)ing mixtures of this kind ready-maide ; and it is probable that the plan of giving at the out- set sufficient chloroform to abolish conscious- ness, and subsequently administering ether, vrill be found safer than mixing them together in the liquid state. Ethidene, ^e. See Appendix. Afteb-tbeatment. — Quietude or conversation of an encouraging or soothing character is de- sirable during the half-minute of recovery from gas. The eyes should be covered, unless the view is tranquil as well as pleasant. If gas be given until there are intermissions in the breathing, or its administration continued for several minutes with a small allowance of air, there may be headache and even vomiting : still no other treatment than repose is needed. After the inhalation of ether a taste will re- main, vaiying with the strength of the vapour, and ib.a duration of the administration. This may be got rid of by washing out the mouth, and gargling with warm fluids ; while tho vapour re- maining about the patient and in the room may ■ ANESTHETICS. be removed hy heating the surface by means of hot bottles, and making a bright fire. When the system has been long or pro- foundly under the influence of chloroform or etl^er, nausea and yomiting are likely to ensue. The writer has not found any remedies more effoient in pelieviug these symptoms '.ban warmth, fresh air, and abstinence from food. Hot tea and coffee, taken from a feeder without raising the head, and afterwards beef-tea and jelly, aje sufftcient for twenty-four hours, unless the patient wishes for something solid. The rule then should be to give as little as, or less than, is asked for. Ice has been recommended, and, if it does nothing else, it relieves thirst, and serves to postpone the necessity for giving solids which might prove hurtful. TEEA.TMBNT OS DANSEBOUa SYMPTOMS. — Au- sesthetics in excess destroy life by stopping the oction of the heart, or the respiration; generally both are affected. When laughing-gas is given to animals tiU the bijeathing has ceased, the heart continues to beat long afterwards, and artificial respiration rapidly restores them. Ether-vapour, given almost pure through a tracheal tube, will arrest the action of a dog's heart in sixteen se- conds ; but if administered as rapidly as possible with a doth, vidthout opening the trachea, the breathing fails before the heart, and the haema- dynamometer shows adequate pressure in the vessels whilst the breath is gasping, and for several seconds after it has ceased. With chloroform the hsemadynamometer indi- cates diminished pressure directly the animal ceases to struggle, and the heart sometimes stops before the breathing. In case alarming symptoms should arise, the first effort should be directed to lessening the amount of the anaesthetic in the lungs, by pressing the trunk with both handSj and squeezing out as much air as possible with-- out causing a shock. If, after this has been done two or three times, the air does not readily' re-enter the chest, the obstruction is to be over- come either by lifting the chin or drawing out the tongue, and other artificial movements of the chest must be. carried on. (See Aetipioiai. Ebspiration.) If pallor be noticed whilst breathing i& going on, the recumbent posture and elevation of the feet are immediately re- quired. {See RBairsorrATiON.) Nelaton's plan of inverting the body has often been foUowed by recovery, but, considering the impediment to inspiration from the weight of the abdominal viscera, the writer is of opinion that the pelvis should never be many inches higher than the head. Nitrite of amyl — by reason of its effect in dilating the vessels of the skin — ^has been recommended, but without careful physiological inquiry, and upon very small clinical experience. Electricity might be expected to prove the best agent to assist the action of a feeble heart. The writer's experimental observation has not been favourable to its employment; and cer- tainly artificial respiration shojJd not b& delayed one moment in order to apply electricity. Insufflation is not to be depended on. The condition would be rendered worse by distending the stomach, which cannot always be prevented by pressing the larynx against t^he spine, Laiyngotomy may be required in cases where in ANAPHEODISIACS. 46 spite of throwing the head backward, and re- moving the chin away from the sternum, air can- not be made to enter the chest. Hot-water iiy ections may be of use, but thero can be no necessity for brandy whilst artificial breathing is being carried on. Afterwards, if swallowing is difficult, brandy may be added to the enema. Friction of the limbs in the direction of the heart is unnecessary, provided the feet are slightly raised,. Where there has been great loss of blood, the limbs should be bandaged firmly &om the fingers and toes upward, as in Esmarch'a plan for saving the blood of a limb about to be amputated. In warm weather, or if the body is warm, a towel dipped in cold water n^y be flap- ped against the chest,, but harm would resijlt from cooling the body generally. Bottles of hot water and hot blankets should be applied as soon as the breathing is restored> - and a brisk fire should be keptup, in order to favour the venti- lation cf the chamber. J. T. Cloveb. AWAIiGrESIA (St, priv., and 8X701, pain). — Absence of sensibility to painful impressionB. See Sensation, Disorders of. AWAPHKODISIA (4, priv., and 'A^poSIxij, ' Venus). — Absence of sexual appetite. Some- times used to express Impotence. See Sexttai EnNCTioNS, Disorders of. AITAPHBODISIACS.— DEFINITION.— Me- dicines which diminish the sexual passipi;. Enumeration. — The agents employed, as ana- phrodisiacs are : — Ice, Cold Baths — local and general; Bromide of Potassium and Ammonium; Iodide of Potassium ; Conium ; Camphor ; Digi- talis ; Purgatives ; Nauaeants ; and Bleeding. Action. — The erection which occurs in the genital organs during functional activity is due to dilatation of the arteries. in their erectile tissues, audi is regulated by a nervous centre situated in the lumbar portion of the spinal cord. From this centre vaso-inhibitory nerves pass to these arteries, and cause them to dilate whenever it is called into action. It may be. excited either reflexly by stimulation of the sensory nerves of the genital organs and ad- joining parts; or by psychical stimuli passing to it' from the brain. Anaphrodisiacs may act by lessening the excitability of the nerves of the genital organs, as the continuous application of cold, and probably, also, bromide of potassium ; by diminishing the excitability of the genital cen- tres in the spinal cord and brain, as bromide and iodide of potassium and conium ; or by influencing the circulation, as digitalis. There are also ad- juvant measures, of a hygienic and moral charac- ter, which greatly assist and may even replace anaphrodisiac medicines, such as a meagre diet, especially of a vegetable nature, the avoidance of stimulants, and the pursuit of active mental and bodily exercise. Everything tend- ing to stimulate the genital organs, or to in- crease the flow of blood to them or to the lumbar portion of the spinal COTd, should be avoided, such as warm and heavy clothing, or pads about the hips or loins ; and a hard mattress should be used in place of a feather-bed. Everything likely to arouse the passions, such as certain M ANAPHRODISIACS. aovels, pictures, theatrical Tepieeentations, &c. should also be shunned. Uses. — Anaphrodisiacs are employed to lessen the sexual pa^isions when these are abnoriuolly excited in satyriasis, nymphomania, and allied conditions. As such excitement may some- times depend on local irritation of the genitals, in conseqasnce of prurigo of the external organs, excoriations of the os uteri, or balanius ; or on the presence of worms in the rectum or yagsna ; these sources of excitement should be locliud for, and, if present, should be subjected to appro- priate treatment. T. Ladder Beuntoit. ANASARCA (avh, through, and uncture. — The first is galvanopunc- ture, in which a current of electricity of low ten- sion, long continued, is passed through the blood in the sac, decomposing it, and causing its coa- gulation. Needles are plunged into the sac, and are then connected with the battery, and the action is continued until the reduction in the pulsation and the flattening of the tumour show that the blood has been partly coagulated. Au- thorities differ as to the details of the method. Some apply first the positive and then the nega- tive pole to each needle, others the negative pole only, the positive being brought in contact with the neighbouring skin, while some on the con- trary use the positive pole only. It will be found on experiment that a certain amount of coagulation takes place around both poles, the clot round the positive pole being smaller but firmer than that round the negative. The ob- ject of the operation is to fill the sac as much as possible with coagulum which shall gradually harden, and shall attract to itself fresh coagula. The dangers of the proceeding are those of inflammation of the sac, or of the cellular tissue around it ; of suppuration within the tumour ; or of sloughing of the punctures and haemor- rhage: and it must be allowed that the effects of galvanopuneture are very uncertain, both as to the amount and firmness of the coagulum produced. Still there is satisfactory evidence of benefit in many cases, and of a cure in a few. The danger of infiaming or cauterising the sac or the tissues around may be in some measure obviated by coating the needles with vulcanite, as recom- mended by Dr. John Duncan of Edinburgh. For a very clear exposition of the details of this method, as well as for statements regarding the success which has attended electrolysis hitherto, the reader is referred to a lecture by this gentleman, reported in the British Medical Journal, May 20, 1S76. The writer thinks himself justified in adding that electrolysis should be restricted to cases of thoracic, subclavian, or abdominal aneurism, which cannot be cured by medical means, and in which rupture seems to be imminent, wliile the situation of the tumour forbids the application of pressure. Coagulating Injections, — Another method of producing coagulation of the blood in the sac is by the use of coagulating injections. Other fluids have been employed, but the only one in general use now is the perchloride of iron. The circulation is to be suspended by pressure on the artery above, before the injection is made and for some time afterwards. The method is a very danger- ous one for large aneurisms, on account of the risks of embolism, sloughing, and inflammation, but it may be used with success in small cirsoid and anastomotic aneurisms, and also in varicose aneurism. Introduction of foreign -bodies. — Aneurisms have also been treated by the introduction of foreign bodies into the sac, with the view of pro- ducing coagulation of the blood upon the foreign substance, such as fine wire, carbolised catgut, and horsehair ; but no case of cure has hitherto been reported. Manipulaiion.— Vinally, aneurisms may bo treated by manipulation. The object of this treatment is either to detach a portion of coagu- 50 ANEUKISln. lam from the wall of the aneurism, which may be carried into the mouth of the sac or the distal arteiy, and so effect a cure as in our second mode of spontaneous cure, or at any rate so to disturb and break up the clot, that its detached- laminae may form nuclei for further coagula- tion. With this view the aneurismal tnmour is grasped between the two hands to squeeze all the fluid blood out of it,' and one wall rubbed against the other till ' a friction of surfaces is felt within the flattened mass.' ' The proceeding is obviously a Tery dangerous and uncertain one, but 'some indubitable cures hare been thus effected. Arteriovenous Aneurisms. — ^A few words must be added with respect to the rarer forms of aneurism. Arteriorenous aneurisms are generally, but not always, traumatic, and are divided into two chief forms : — 1. Varicose aneurism, in which there is a small aneurismal tumour communicat- ing both with the artery and with a vein which is always varicose ; and 2. Aneurismal varix, in which the opening between the two vessels is direct without any tumour interposed ; the vein pulsates as well as being varicose, and the tempe- rature of the limb and nutrition of the skin and hair are increased. In all forms of arterio- venous aneurism the artery after a time becomes thin and much dilated. The signs of arterio- venous differ from those of arterial aneurism mainly in this — that besides the intermittent blowing murmur caused by the arterial current, there is a continuous purring or rasping, bruit due to the venous current ; and that besides the intermittent pulsation there is a continuous thrill. Varicose aneurism may be cured by digital pres- sure applied directly to the venous orifice, and indirectly to the artery above at the same time ; or the old operation may be performed, the clots being turned out of the sac and the artery tied above and below, the vein being of course laid open and secured either by ligature or pressure ; or the artery may be tied above and below without opening the sac. Electropuncture and coagulating injections have also been used with success. Aneurismal varix does not usually require or admit of surgical treatment. If it does, the ligature of both parts of the artery is the only measure that can bo adopted, on the failure of compression. Cirsoid and Anastomotic Aneurisms,— Cirsoid aneurism, or arterial varix, is a tumour formed by the coils of a single dilated and elon- gated artery ; ' while aneurism by anastomosis is a tumour formed by the coils of numerous di- lated and elongated arteries, with the dilated capillaries and veins which communicate with those arteries. It is often difficult to distinguish these two forms of arterial disease from each other. Aneurism by anastomosis frequently origi- nates congenitally as one of the forms of nsevus. The usual situation of these tumours is on the scalp. Thoy have often a peculiar continuous buzzing or rushing murmur, which is propagated over Uie whole head, and much disturbs the patient's rest ; while they are liable to ulcerate and to become the source of serious and even fatal hemorrhage. Some cases of spontaneous cure ' Sir TV. Pergu83on, Med. Chir. Trans, il. 8. " Bee the figure on p. 534, vol. lii. of the System of Riri/erj/, 2nd edition. ANOINa pectoeis. are on Tecord. Very numerous methods of treat- ment have been employed, of which the writer can only mention those which are most generally use- ful. When feasible, the total removal of the tumour with the knife is certain to effect a radical cure, but this operation is often too dangerous to bo attempted. The entire removal by ligature is still more rarely practicable. The galvanic cautery is often successful ; the incandescent wire being drawn through the mass in varions directions divides it into portions, and obliterates the vessels by producing cicatrices at the parts cauterised. Setons havfe also been used with success, when combined with the ligature of the trunk-artery ; and the ligature of the artery alone has been said to be followed by success, but certainly is generally unsuccessful. Finally, coagulating iojections and galvanopunoture have both effected a certain number of cures. T. HOLMSS. ABTGEIECTASIA (iyyeioi/, a vessel, and fKTaais, extension). — Extension or hypertrophy of the capilla,ries and minute vessels of. the sur- faces of the body, especially the skin; hence angieiectasia capillaris, a term appli cable to several forms of vascular naevns. AWG-BIOIiEUCITIS (ay-yfioy, a vessel, and Kevxhs, white). — Inflammation of lymphatic vessels. See Lymphatic System, Diseases of. ANGIITA (fiyx", I seize by the throat, strangle, or choke). — Synon. : — Fr. angine ; Ger, die BrSune, The term angina was originally applied by Latin writers on Physic, and is still much used on the Continent, to indicate a condition in which dif- ficulty of breathing and of swallowing exist either together or separately, caused by disease, situ- ated between the mouth and the lungs, or between the mouth and the stomach. By a special affix to the original term, significative of the seat or the nature of the disease, several varieties of morbid states are known and described, for example : — angina parotidea, or mumps ; angina tonsillaris, or quinsy ; angina laryngea, or laryngitis ; «»- gina pectoris, or breast-pang ; angina maligna, or malignant sore throat. ; angina membranosa, or croup. These and numerous other diseases, differing essentib,lly in their nature and pathological rela- tions, and having nothing in common but certain difficulties in breathing or swallowing, are thus classed under the word angina. Such a classifi- cation is open to several objections, and has nothing to recommend it. With the exception, therefore, of angina pectoris, which has a special and familiar signification, the various diseases occasionally recognised by the term angina will be found described under the names by which they are generally known in this country. See also Cynanche. E. Quain, M.D. AWGIITA PECTOBIS.— Synon.: Syncope Anginosa ; Angor Pectoris ; Suffocative Breast- pang. Fr. Angine de poitrine; Ger. Brust- brSune. Definition. — An affection of the chest, cha- racterised by severe pain, faintness, and anxiety, occurring in paroxysms : connected with disorders of the pneumogastric and sympathetic nerves and ANGINA PECTORIS. 61 their branches ; and frequently associated with organic disease of the heart. Desceiptiok. — An attack of angina pectoris commences suddenly with pain in the region of the heart, generally on a level with the lower end of the sternum. The pain is severe, and of a grasping, crushing, or stabbing cliaracter ; it extends sometimes across the chest, but more frequently backwards to the scapula, and up- wawls to the left shoulder and arm. The pain is accompanied by a distressing sense of sink- ing, of faintness, or of impending death. The action of the heart is generally irregulai*. The pulse at the wrist corresponds ; but in some well-marked cases it is regular, tense, and resist- ing. A fear of aggravating the pain prevents the patient from breathing, though the respiratory function may not be really interfered with. The expression is anxious, the face is pallid, and the lips are more or less livid. The whole surface of the body is pale, cold, and covered with a clammy sweat. Flatulence is often present ; urine in some cases is passed at short intervals, and generally in abundance. The sense of faintness causes the patient to seek support, and he rests on any object by which this may be obtained. The attack having lasted for a variable time — from a few minutes to one or two hours^oomes to an end, either by a sudden cessation of the more urgent symptoms, or by their gradual disappearance. The pallor and coldness of the surface are replaced by a uniform glow — the face may even flush, the t)ulse becoming soft and full, and there is a general feeling of relief; a sense of numbness or tingling along the course of the nerves derived from the brachial and cervical plexuses of the affected side occasionally remains. An attack of angina pectoris frequently comes on daring sleep; but it may be induced by emotion or by physical exertion, especially by walking up an ascent, or by exposure to cold air or wind. An attack of this kind may occur but once and end fatally; -or it may recur after an interval of hours, days, or weeks, and be thus continued ; or there may be an interval even of years. These and other modificatioiis of the disease will be again referred to. Pathologt. — The nature of the aggregate of the symptoms or phenomena comprised under the name aiif^ina^ecionsl cannot be understood with- out a clear apprehension of the relations of the nerve-elements of the organs and regions that seem to be involved in the affection. It will be well brieflyto summarise them. The nerves chiefly involved are the pneumo- gastric and the sympathetic, and their branches, which nerves, it should here be stated, are con- nected with each other at their origin in the medulla oblongata, in their course," and in their distribution to the ganglia and structures of the heart. They also communicate with certain of the cerebral nerves, and with the cervical and brachial plexuses. Which supply part of the head and neck, the arms, the diaphragm, and the chest-waUs. Their connections with the heart are very extensive. This organ is supplied by the cardiac ganglia and the branches derived from them, which are in relation with, and, in fact, constitute part of the cardiac plexus formed by the interlacement of branches from the pneumogastric and the sympathetic nerves. The pneumogastric supplies the superior cardiac nerve and apparently the inferior cardiac nervo (which, however, is derived from the spinal accessory, and is merely distributed with tho pneumogastric)^ the sympathetic contributes several branches through the cervical ganglia. Branches of both pneumogastric and sympathetic nerves are distributed to the respiratory pas- sages, the lungs, stomach, intestines, liver, and other abdominal viscera. > The connection of the pneumogastric and sympathetic nerves in the medulla, to which allusion has been made, occurs at the cardiac and vaso-motor centres ; and consequently these nerves, and the heart (which they supply) are thus brought into relation with the vaso-m6t(» nerves throughout the body, and with all the systemic blood-vessels ; they are also in relation with the other important centres in the neigh- bourhood ; and with the cerebrum itself, more especially that part of it associated with the emotions. . < Such being the distribution and the relation of the nerves connected with the heart and sur- rounding parts, we learn, in reference to their functions, that the movements of the heart are maintainedby its ganglia, but that. these move- ments may be ■ accelerated by the action of the sympathetic, whilst they are controlled and may be even arrested by that of the inferior cardiac branch from the pneumogastricj The superior cardiac branch of the pneumo- gastric has to do with the speciflc function of conveying impressions contripetally from the heart to the medulla, whence these impressions may be' reflected through the inferior cardiac nerve to the heart, controlling for a time its movements ; and also reflected through the vaso- motor centre and vaso-motor nerves, to the general circulation. By means of this latter functional relation, relaxation of the arteries, especially those of the abdomen through the splanchnic nerves is accomplished, and the heart is relieved of pressure. With regard to other functions of the cardiac nerves, it is believed that such common sensi- bility as the heart possesses is more especially connected with the superior cardiac branch of the pneumogastric. Numerous communications exist between this nerve and the ordinary spinal nerves; and it must also be remembered in reference to the sites of pain in angina,' that nerves may be -rendered sensitive by disease which are not sensitive in health. Lastly, it is to be noted that the pneumogas- tric and sympathetic nerves, as well as the heart and blood-vessels, whose functions they regulate, possess the extensive connections above mentioned with the abdominal and thoracic viscera, and thus they not only influence but are influenced by the conditions of the lungs, liver, stomach, kidneyS, and other organs. Keeping in mind this distribution of nerves and their functions^ we can recognise how the movements of the heart may be affected, whether in the direction of acceleration, retardation, or even arrest. We can further understand how painful impressions oi:iginating in the cardiac nerves may be propagated so as to be refenod 63 ANGINA PECTOEIS. to the associated sensory nerves and their branches ; and hovr relations may be established with the Taso-motor system and the circula- tion generally. Thus the vessels throughout the body may be acted upon, producing cold- ness and pallor of surface from the abnormal filling of the abdominal at the expense of the superiicial vessels, a condition which seems to be the canse of the diminished arterial ten- sion noticed in these cases. We can also com- prehend how morbid impressions made either on these nerves, in their distribution to the abdominal viscera or the heart, or on the peripheral distribution of the vaso-motor nerves at the surface of the body, may, passing cen- tripetally, admit of reflex impressions and re- flex actions, which in some cases may be pro- vocative of the symptoms of this disease : also how direct impressions made on the nerves themselves in their course, or at the vaso-motor centre, or through the cerebral emotive centres, may each give rise to the phenomena which represent the symptoms constituting angina pec- toris. Pathology of Uncomplicated Angina Pectoris.— That this disease is dependent on an affection of nerves may be held to be demonstrated by the paroxysmal character of the attack ; by its sadden access and sudden departure; by the nature of the causes that promote it, whether they be mental emotion or direct or reflected irritation ; by the course and character of the pain, and by the fact that in severe — even fatal — in- stances of angina, there is often an absence of any tangible or evident organic local disease. The morbid state affecting the nerves may be situated in the medulla ; or it may be in the course of these nerves, or in their branches ; or in the cardiac ganglia themselves. It may be the result of congestion or inflammation of the nerve, such as occurs in the lithic acid or jouty diathesis ; or of other textural changes, such as connective-tissue growth, involving the nerve-fibres and ganglia. It may be produced by emotions acting ceptrifugally ; or by'irritation acting centripetally, reflected, as we have just said, from impressions made on the peripheral extremities of nerves. Thus acidity of the stomach distended by flatus, the result of indiges- iion, often gives rise to symptoms which very !losely resemble, if they do not constitute, an ittack of angina. The like efTect has been pro- iuced by irritation reflected from the flfth nerve, ts, for example, in pivoting teeth ; by such irrita- tion of the .surface of the skin as results from ievere herpes ; by cold, or by exposure to wind. But the most frequent source of the symptoms )f ajigina caused by reflex action is to be found n those organic affections of the heart which viU be described in the next section. Whatever the nature of the irritation or of he exciting cause, the symptoms will, in some neasure, bear a relation to the nerves affected. Thus, if the sensory branches connected with he spinal nerves suffer, we shall probably have )ain more severe and more diffused: whereas f the branches more immediately supplying the leart are affected, we shall have the action of hat organ more or less disturbed, accelerated or lepressed. And so with the branches of other nerves, more especially of those connected with the vaso-motor system, or with the lungs and abdominal viscera, modifications of symptoms are produced which it is needless to describe at this point in detail. Pathology of Angina Pectoris cornpUcated with Organic Disease of the Heart and Vessels. — The striking character of the symptoms of angina pectoris has led pathologists to connect the heart with the disease, and to investigate its condition accordingly. Such researches have established the fact already mentioned, that angina may exist without any discoverable disease in the heart or its appendages. On the other hand, in the great majority of cases various forms of structural disease of the heart and aorta have been ob- served ; for example atheromatous or calcareous degeneration in thecoronaryarterieSjinthevalves, or in the aorta ; dilatation of the cavities of the heart, or of the aorta ; accumulation of fat in the cardiac walls ; and lastly, and probably the most important change of all, fatty degeneration of the muscular tissue. A knowledge of this lesion is of comparatively recent date ; it is constantly associated vrith the calcareous and atheromatous diseases described above, and which alone at- \ tracted the notice of older observers. Nay more, this lesion of the walls of the heart is in itself a frequent and sufficient cause of one of the most prominent symptoms of angina pectoris— faint- ness. This condition has been elsewhere described by the present writer (Medical and Chirwgical Sodetps Transactions, vol. xxxiii.) under the name of Syncope^ Leihalis or fatal- faintness — a designation analogous to that given by Parry to angina pectoris, which he called Syncope Anginosa. iEiioLooy. — ^When treating of the pathology of angina pectoris we have already discussed the conditions under which it occurs. We have endeavoured to show that the disease consists in a lesion of certain nerves, associated with various morbid conditions. In seeking to in- dicate the predi^odng causes of these condi- tions, we have to point out (1) the existence of a peculiar state of the nervous system, which may be described as an undue susceptibility to impressions. What that state is we know not. It would seem to be often hereditary, and to be found in those temperaments in which there is a high development of the nervous element, associated with certain habits of life, such as sedentary employments, high living, and so on. Thus it is that this disease has been the cause of the death of many men who, by their intel- lectual parts, have left their mark on history. It is merely necessary to mention, as instances. Lord Clarendon, John Hunter, Dr. Arnold, (2) The influence of age is conspicuous ; the disease is rare before puberty ; and the writer's researches show that quite eighty per cent, oi cases occur after forty years of age. (3) Sex also displays a marked influence on the dis- ease ; it is comparatively rare amongst women, a statement by the late Sir John Forbes show- ing that out of 49 fatal cases, only 2 occurred ill females ; and 4 out of 15 non-fatal eases — facta entirely corresponding with the writer's expe- rience. (4) The peculiar diathesis Which gives rise to neuralgia of various parts, and that iu ANGINA PECTOEIS. 53 ■which lithio acid predominates in the system, would seem to be in many cases an efficient cause of the symptoms of angina. The exdtmg causes of angina pectoris are (1) Those that affect the nerve-textures themselves. (2) The condition to which we have referred, in which organic disease of the heart exists. (3) Mental emotion, especially anger or nervous ehook. (4) Irritation propagated oentripetally from the surface, as by the branches of the fifth nerve ; through the brachial plexus ; through the sympathetic and pneumogastric nerves distributed to the abdominal viscera. (6) Cold applied to the surface, and especially cold winds. (6) Physical exertion, or any other agency by which the circulation is quickened. (7) Depressing agents, such as excessive tobacco-smoking, malaria, &c. Anatomioai Chauactbbs. — Beyond the con- ditions indicated under the head of Pathology, there is little to be said on the morbid anatomy of angina pectoris. These several conditions, and the symptoms of angina as above described have been found to exist independently of each other. There must therefore be something in the state of the nervous tissues that acts as the pre- disposing or exciting cause of this aggregate of phenomena. Inflammatory changes and tumours, involving the vagus or the cardiac plexus, have been observed and described. With reference to the state of the heart itself, its cavities have been found dilated and. containing blood; or con- tracted and empty ; and theories have been founded thereupon, as to whether death occurred by spasm or by paralysis. It is more than probable that either one or the other of these conditions may occur in angina, and lead to fatal results, accord- ing to the particular nerves controlling the func- tions of the heart which are affected. See Pjjbu- MOQASTRic Nerve, Disease of. Clinical Vabibpies. — AU the phenomena of an anginal seizure as above described may be more or less modified. The attack, though gene- rally induced by exertion, may come on when the patient is at rest, and not unfrequently it sets in during sleep. The pain may be comparatively Blight, and as such may recur occasionally, it may be, for months or years. On the other hand, it maybe so severe as to mark a first, a single, and a fatal attack. In its character the pain may be stabbing or burning ; but it is more fre- quently described as grasping, crushing, or op- pressive. It may be limited almost to the region of the heart, or the lower part of the sternum ; it may extend aU over the chest to both arms, or spread, to the side of the head and neck and down one or both legs,; and it may in some cases apparently involve the diaphragm. The action of the heart may be slow, weak, and fluttering ; or excited and bounding — constituting palpita- tion ; and it may be regular or irregular. The pulse corresponds. with the heart's action ; in the earlystage of a genuine attack itsometimes yields a sphygmographic tracing indicative of extremely high tension. The breathing is sometimes dis- tressing ; and although the patient can take a deep breath when asked to do so, he generally avoids this through fear of aggravating the pain. There may be laryngeal spasm. The mental foBctions are generally undisturbed ; yet there is sometimes slight wandering as the attack passes off, and unconsciousness is said to be occasionally observed. The sense of danger of impending death is a characteristic symptom of angina, and one not often absent;; whihit a sensation of gasping or choking with difficulty in swallowing is occasionally present. The position of the patient varies ; sometimes he sits, sometimes he stands, resting his arms on an^ convenient object to obtain support ; sometimes he sits and stoops, or leans forward. As a rule the attack passes off as abruptly as it commenced, leaving the sufferer free from discomfort ; in other cases its disappearance is more slow. The varieties in the symptoms of angina pectoris are thus seen to be remarkably numerous, constituting a form of disease which may be comparatively mild and of long duration, or one of intense suffering, hastening to a fatal termination.' Complications. — Amongst the diseases with which angina pectoris may be said to be asso- ciated, rather than complicated, are disorders of the liver and digestive functions, gout, albu- minuria, diabetes, and certain diseases of the nervous system. Indeed, so marked is the latter connexion, that Trousseau dwelt on the relation between epilepsy and angina — a relation which seems to depend on the susceptibility to nervous maladies which some individuals present, rather than on any special identity between these two diseases. More than one striking example of the connexion has fallen under the wri:;er's notice ; he might mention an instance recently met with in which this susceptibility was such, that an oppressive meal of indigestible food brought on a first and distressing anginal attack, followed by others. . In this, case brain disease with epilepsy was subsequently developed on the disappearance of the angina. Peogeess, Dxieation, and Teeminations. — The progress and duration of this disease will depend wholly upon the nature of its cause. Cases have been recorded in which the first attack proved fatal. The writer has seen several ; in three of these casesa post-moftem examination revealed the fact that there was slight partial hemorrhage into the walls of the heart, which had been the seat of fatty degeneration, con- nected with calcification of the coronary arteries. The symptoms in these cases perfectly resembled those of the most severe examples of angina pectoris. It is highly probable, therefore, that * A case has recently come under the writer's notice in which a gentleman accustomed to pass lithio acid, and who for several years has had pains over the right side o£ the chest as low as the hypochondrium, was seized at night with a severe aggravation of these, pains, coldness o£ the surface. Irregular action of the heart, depression, and other symptoms, which, had the attack commenced on the left side of the chest, would have been really called angina pectoris. Similar attacks recurred at intervals for some weeks ; they were easily brought on even by walking on a level surface for a few hundred yards. The most careful examination failed to elicit any evidence of organic disease in the organs of circulation or respiration. The patient was recommended to try a course of Hombnrg waters, and a short residence in Switzerland ; from which he returned greatly improved, and almost free from pain. It should be mentioned that an interesting case has recently been recorded by lir. Morison in which disease of the right side of the heart was accompanied by symptoms of angina affecting the corresponding side of the chest and arm. ii ANGINA PECTOEIS. some of the cases prOTing' fatal in a first attack of the : disease are rather examples of partial rupture of the heart than of what is usually called angina. On the other hand, cases of the disease may continue with interruptions for years ; the difference being entirely due to the nature of the cause on which the disease depends. Thus in many instances individuals present aU the symptoms of marked angina, accompanied by most of its distressing pheno- mena, and by the anxieties and fears that they beget ; yet these cases, having more a neurotic or gouty origin, yield to treatmenti the sufferers being restored to health, and continuing for years to enjoy comparative comfort. On the contrary, in the cases in which' angina is con- nected with organic disease of the heart or of the nerves intimately connected with cardiac action, the symptoms progress in frequency and 'severity ; and the attacks tend, with more or less certainty, to a fatal termination — it may bo within a few days or weeks, or it may be, in milder cases, not for years. Diagnosis A typical case of angina pectoris, such as has been described at the commencement of this article, can hardly be mistaken. But when the several symptoms constituting an attack are variously modified, some being lessened in severity and others exaggerated ; or when these symptoms depend on, so to speakj remote and removable causes ; it is often difficult to~say how far the disease is what may be regarded as a passing neuralgia, or an attack of what is com- monly recognised as angina pectoris. So also it maybe difficult to say, in casesof angina,'whetiher- the seizure is dependent on organic lesions which admit of no improvement, or on some oon- flition that is amenable to treatment. It is; therefore, with this, as with most other affec- tions, more difficult to determine the cause on which the symptoms depend, than to recognise the presence of' the disease itSelf. With re- ference to the diagnosis of the organic dis- eases of the heart above alluded to, it is un- necessary to repeat here what will be found described under other heads. It remains but to say that in every case the closest scrutiny must be made into • the condition of the heart and great blood-vessels, with a view to determine the presence or absence of organic disease. The iijvesliigatiojl must further extend to the other viscera, suteh as the liver, stomach, and the diges- tive organs generally, as well as to the several other sources from which symptoms of angina may be excited by reflected irritation. Certain symp- toms resulting from the presence of other diseases should not be confounded with angina — such, for example, as the pain and dyspncea caused by pressure of aneurisms or of tumours within the chest ; by rheumatic or gouty neuralgia of the chest-walls; bypleurodynia, or acute pleurisy ; or by indigestion. Each and all of these conditions must be considered by way of exclusion in de- termining the nature and origin of the disease. Peoonosis. — In anticipating the future of an attack of angina pectoris, one must be guided chie6y by a knowledge of its cause; in Some respects also by its severity ; and by the previous history of the case. Thus, if we can ascertain that the attack has been brought ANGINA PECTOEIS. on by some clearly established and remov* able cause, a favourable prognosis ma.y> be fairly entertained. On the other hand, if the history of the case tells that there have been several previous attacks, increasing in severity and connected with heart-disease, one can scarcely avoid being led to the conclusion that the disease will tend, with more or less rapidity, to a fatal termination. Between these two classes of cases exist a large majority of the examples of the disease in which the symptoms of angina, of greater or less severity, depend on neurosis, on gouty diathesis, or on other sources of nerve disorder, amenable to treatment ; and in which, therefore, a favourable prognosis may to some extent be given. But in all cases great caution should be exercised ; for many instances occur in which, from slight and obscure beginnings, severe and even fatal examples of the disease have been developed. Teeatment. — The treatment of angina pec- toris must first have reference to relief, of the attack itself; and, secondly, during the inter- val to the removal of the causes on which the attacks may depend. Spring the attack, it is necessary first, if pos- sible, to inspire confidence, and remove appre- hension. The patient should be allowed to retain the position in which he feels most comfort. Secondly, if the exciting cause is one that can be removed, this should be done ; for example, if the stomach be full of undigested food,' an emetic of mustard might be. given with ad- vantage ; or if flatulence be present, peppermint, ether,- and other anti-spasmodics will be useful. If cold have produced the seizure, the feet and hands should be i immersed in hot water, hot bottles applied to the surface of' the body, and poultices of linseed or mustard, or embrocations of chloroform or laudanum, should be placed on the chest. The administration of chloroform internally had better be avoided. The nitrite of amyl, as recommended by Dr. Lauder Brunton, has been found one of the most efficient remedies employed hitherto. Pive or six minims of this drug (preserved in a glass capsule) should be in- haled from a handkerchief, and, if necessary, the inhalation may be repeated. Nitro-glycerine is useful (jij of a minim dose), and hypodermic injection of morphia may be tried with advan- tage. In cases where- debility and exhaustion exist, the ordinary stimulants will be r«quir«l ; and various antispasmodics, such as ether, ammonia, &e., may be given with more or less benefit. . During the intervaU.— It is of course desi- rable to avoid all causes likely to bring on an attack of angina, such as inental excitement, bodily exertion, exposure to cold, and the use of indigestible food or heavy meals. The leading principle in treatment should, however, be to endeavour to determine and to remove, if pos- sible, the cause of the disease. Whether it de- pend on organic disease of the heart, whether on simple neuralgia, whether on gout or dys- pepsia, whether on debility, or on fulness of habit — to each of such conditions mustappropriate treatment be directed. A variety of specific remedies have been recommended: such as arsenic, phosphorus, steel, zinc, and the different ANGINA PEOT.OBIS. &nti-spasmodic8. GalTanism, in the form of the continuous current from thirty cells, has proved successful in some uncomplicated cases, the positive pole being placed on the sternum, and the negative on the lower cervical vertebrse. Ex- cellent, however, as each of the remedies named may be under special and suitable circum- stances, the result of treatment must entirely de- pend on the caose of the disease, and how far it is within reach of remedy. Some cases of ap- parently severe angina will be found to yield to treatment ; whilst, aa might be expected from the nature of the disease, others unhappily pro- ceed to a fatal termination in spite of every effort directed to their relief. E. QuAiN, M.D. AlflDBOSIS (&, priv., and IBpas, sweat). — Absence or want of perspiration. See Pbespi- HATION, Disorders of. AITILIWB POISON.— The aniline dyes, which are a modern discovery, present the most brilliant hues of yellow, blue, and red ; as such they have been used for dyeing stockings, gloves, &o. These articles when worn are apt to pro- duce an intense form of inflammation and vesi- cation of the skin, which is rebellious against treatment, and liable to relapse for many months after the original attack has subsided. See Dehmatitis. ANIMAL POISONS. See Poisons. ANODYNES (4, priv., and oSivri, pain)» — ^DEFmrnoN, — Medicines which relieve pain by lessening the excitability of nerves or of nerve-centres. ENnMEEATiON. — ^Anodyne medicines include Opium and its alkaloids — Morphia and Codeia ; Bromide of Potassium ; Cannabis Indica ; Bella- donna and its alkaloid — Atropia ; Hyoscyamus and Hyoscyamin ; Stramonium; Aconite and Aconitia ; Veratrum and Veratria ; Conium and Conia ; Lupulus and Lupulin ; Gelseminum ; Chloroform, Ether, and their allies; Chloral- hydrate; Butyl-ohloral-hydrate ; and Camphor. AoTioir. — Pain is due to a violent stimulation of a sensory nerve being conveyed to some of the encephalic nerve-centres (probably the cerebral hemispheres), and perceived there. The impres- sion produced on all sensory nerves, except the cephalic nerves, is conveyed for apart of its course to the head along the spinal cord. The primary impression which is felt as pain, is usuaUymade upon the peripheral ends of the sensory nerves ; but it may also be made upon their trunks, upon the spinal cord, or possibly upon the en- cephalic centres directly, without any affection of the, nerves themselves, as, for example, in hysteria. Pain may therefore be relieved, while the source of irritation still remains, by lessening the ex- citability of the ends of the sensory nerves which receive the painful impression ; of their trunks ; of the spinal cord along which the impression travels ; or of the encephalic centre in which it is perceived. Opium acts by lessening the excitability of the sensory nerves, the spinal cord, and the encephalic ganglia ; bromide of potassium is also believed to act on all three, although to a much less degree than opium ; belladonna and atropia affect the sensory nerves, as probably does hyoscyamus; ANTACIDS. S6 stramonium, aconite and aconitia, veratria, chloral and butyl-chloral, lupulus and lupulin, and gelseminum probably act on the encepharu? centres. Uses. — As opium and morphia act upon all the nervous structures concerned in the production of pain, they may be used to relieve pain what- ever its cause. Cannabis indica and bromide of potassium may be employed under the same circumstances as opium, but they have very much less power. Chloral seems to relieve pain only by inducing sleep, and does not produce an ansesthetic effect unless it is given in dangerous doses. Butyl-chloral also induces sleep, but seems to have a special sedative action on the fifth nerve ; so likewise has gelseminum — and hencs both these agents are used in the treatment of facial neuralgia. As the action of belladonna is exerted chiefly on the peripheral ends of the sen- sory nerves,, this remedy is usually applied directly to the painful part in the form of plaster, liniment, or ointment. Aconite, veratria, and opium are also used as local applications in several forms, for the relief of pain. The various anodynes may be administered not only by the mouth, but by other channels, such aa by inhala- tion, by enema or suppository, by hypodermic injection, or by endermio application. Several therapeutic measures are employed as Anodynes, such as the application of Dry or MoistiHeat ; Cold ; Electricity ; various forms of Counter-Irritation; Acupuncture; or the Ab- straction of Blood. ni T -n 1. liAm>EB Bkuhton. _ ANOBEXIA (o, priv., and Spells, appe- tite). — Want or deficiency of appetite, not ac- companied with disgust for food. See Appetite, Morbid conditions of. ANOSMIA (4, priv., and oa'fiTi, smBll). — ^Loss of the sense of smell. See SMsii, Disorders of. ANTACIDS. — Depikition. — Medicines used to counteract acidity of the secretions. ENrMEBATioN. — The antadds include Potash, Soda, Lithia, Ammonia, Lime, Magnesia, and their carbonates ; as well as the salts which tht alkalis form with Vegetable acids, such as Ace tates. Citrates, and Tartrates. Action.— Antacids are divided into (1) those which act directly, lessening acidity m thw stomach; and (2) those which act remotely, diminishing acidity of the urine. The alkalis and alkaline earths and their carbonates, with the exception of ammonia, have both a direct and a remote influence ; for when swallowed they act on the stomach, a,nd being absorbed from the intes- tinal canal, they are excreted by the kidneys, thus lessening the acidity of the urin^. Ammonia and its carbonate are direct but not remote antacids ; for, although they neutralize acidity in the stomach, they are partly excreted in the form of urea, and do not diminish the acidity of the urine. The acetates, citrates, and tartrates of the alkalis and alkaline earths, on the other hand, have no antacid effect in the stomach, but undergo combustion in the blood, being converted into carbonates, in, which form they ara excreted in the, urine, and diminish its acidity. Uses. — ^Excessive acidity of the contents of the stomach gives rise to acid erucihaonB and Ji.a xjx\j±ua. An X AU yjl^±i3iML, heartburn. It may eometimes depend on the secretion of a too add juice by the stomach, but probably is generally caused by the forma- tion of acid from the decomposition of food when the process of digestion is slow and im- perfect. Antacids are given after meals to lessen acidity in the stomach, and afford imme- diate relief to its attendant symptoms. They may prove even more efficacious by preventing acidity when given before meals (see Aikalis). [f the action of the bowels be regular, soda is preferable ; but lime should be used if they are relaxed, and magnesia if there is a tendency to constipation. Remote antacids are given to lessen the acidity and irritating qualities of the urine in cystitis and gonorrhoea ; and to prevent the deposition of uric acid gravel or calculus in gouty persons. For this purpose potash and lithia are preferable, as their urates are more soluble than those of the other bases. T. Laxtdbe Beunton. AWT AGOHISM.— This term is employed to express the fact that the physiological action of certain substances may be affected, even to the extent of neutralisation, by the presence in the body, at the same time, of other substances having an action of an opposite character. It is important to distinguish between antidotal action and ph/aiological antagonism. By an antidote is meant a substance which so affects the chemical or physical characters of a poison, as to prevent its having any injurious action on living animal tissues. Thus acids and alkalies neutralise each other, so as to form innocuous salts ; tannin may render tartar-emetic and many vegetable alkaloids insoluble ; and the hydrated sesquioxide of iron may be used to precipitate arsenious acid. In these cases, the action is limited chiefly to the alimentary canal ; and the object of administering the antidote is to form insoluble salts, or compounds which will be physiologically inert. But the physiolo- gical antagonism of certain substances is pre- sumed to take place in the blood or in the tissues. When such a substance as strychnia, for example, is introduced into the alimentary canal, it is quickly absorbed, and carried by the blood throughout the body. It does not, so far as observation has discovered, influence all the tis- sues ; but it so affects the spinal cord, and pos- sibly the brain, as to give rise to severe tetanic convulsions, chiefly of a reflex character. This Dffectis, no doubt, diie either to some interference in the nutritional changes between the blood and the tissues composing the nerve-centres ; or to some specific action of the poison on the aerve-centres themselves {see Apfinitt). These ;ha,nges, which are termed physiological, and on which the normal action of the nerve-centres lepends, are probably of a molecular or chemical oature ; and it is possible to conceive that they nay be modified in different ways by different rabstances. Thus has arisen the idea of phy- siological antagonism ; and experiment has ihown that, within certain limits, which will no loubt vary in each case, such an antagonism is possible. Antagonism maybe either local, affect- ng one organ, as is seen in the opposite effects ipon the pupil of opium or morphia upon the one hand, and stramonium, hyoscyamus,' or bel- ladonna upon the other; or it may extend apparently to more important organs or groups of organs, as in the case of the antagonism between strychnia and the hydrate of chloral. The most important investigations upon the subject of physiological antagonism are the fol- lowing : — (1) Fhysostigma and Atropia, by Professor Fraser — an inquiry which showed' that the fatal effect of three and a half times the mini- mum fatal dose of physostigma may be prevented by atropia. (2) Atropia and Prussia Acid, a research by Preyer of Jena — of a more doubtful character as regards the point to be proved, but still sufficient to show that, within certain limits not yet indicated, it is possible to prevent the fatal action of prussic acid by atropia. (3) Atropia and Muscarin (the active principle of Agaricm muscarius) : — which were found by Schmiedeberg and Koppe to have entirely antagonistic actions on the ganglia of the heart — muscarin exciting the intra-cardiac inhibitory centres, and stopping the heart in diastole, while atropia has the contrary effect. (4) Chloral and Strychnia, — an anta- gonism first pointed out by Oscar Liebreich, who showed that minute doses of strychnia might so rouse an animal from the effects of an overdose of chloral as even to save its life. And (6) Strychnia and Chloral — with respect to which Hughes Bennett demonstrated the converse of the last-mentioned observation, namely, that in the rabbit a fatal dose of strychnia might be so antagonised by a dose of chloral as to save life. Conclusions. — It has unfortunately to be admitted that the practical results of the pre- ceding researches have not been very encouraging. In all of these investigations it was quite ap- parent that the limits of physiological antagonism were very narrow. Three elements affect the chances of success in the way of saving life : — (1) the age and strength of the animal ; (2) the amount of the doses of the two active substances — so that if either the one or the other active substance be given slightly in excess, death will probably take place ; and (3) the time between the administration of the two active substances. If the stronger be introduced first, and be allowed to manifest distinctly its physiological action, it is almost impossible to counteract this by that of another substance ; but if the two substances be introduced simultaneously, or if the supposed antagonist to the more active substance be introduced first, the chances of success are much greater. It is apparent, there- fore, that the facts relating to physiological anta- gonism at present known in science do not hold out much hope of good results from their application in practice ; but still the physiolo- gical facts are so definite as to indicate a precise mode of treatment. For example, no one ac- quainted with the investigations mentioned above would hesitate in attempting to relieve the tetanic spasms of a case of poisoning by strychnia by repeated doses of hydrate of chloral, ot by the administration of chloroform. A practical result of such researches is that the principle of physiological antagonism may serve as a guide to the application of re ANTAGONISM. medies in disease. Thus excessive secretion, say from mucous membranes or from sali- vary glands, may be modified or arrested by the use of sulphate of atropia, a striking ex- perimental demonstration of which may be seen in the antagonism between bromal hydrate and sulphate of atropia in the rabbit. John G. McKendeicx, ANTEFLEXIOir. — ^A bending forwards of any organ. The term is s^ieeially used in rela- tion to the uterus, when this organ is bent for- wards at the line of junction of its body and cervix. See WouB, Diseases of. ANTEVEBSION. — A displacement for- wards of any organ. The term is particularly applied to a change of position of the uterus, in which this organ is bodily displaced in the pelvic cavity, so that the fundus is directed against the bladder, and the cervix towards the sacrum. See WoMS, Diseases of. ABTTHBIiMIIirTIOS (owl, against, and cK/uvs, a worm). — ^Definition. — Medicines which kill or expel intestinal worms. Endmbration. — The principal anthelmintics are : — Oil of Male Fern j Kamala ; Kousso ; Oil of Turpentine ; Pomegranate Koot ; Worm-seed and its active principle. Santonin ; Areca ; Mu- cuna ; Bue ; and drastic purgatives. As purga- tives only expel the worms, they are termed Vermifuges ; while the other anthelmintics which kill the worms are called Vermicides. Action. — The oil of male fern, kamala, kousso, oil of turpentine, and bark of pomegranate root, acfi as poisons to tape-worms ; worm -seed and ■ai itonin ki 11 round- wonns,and also thread- worms. Castor oil, jalapi scammony, and other purgatives do not kill the worms, but dislodge and expel them, by the increased peristaltic action which they occasion. Uses. — ^Drastic purgatives may be used for worms of any sort ; arecafor both tape- and round- worms ; and the other agents for the worms on which they severally act as poisons. Vermicides are generally given after the patient has fasted for several hours, in order that, the intestines being empty, the drugs may act more readily on the worms. A piugative is usually given some hours afterwards, in order to expel the dead worms. As thread-worms chiefly inhabit the rectum, they are most effectually killed by enemata, which may consist of a strong infusion of quassia ; salt and water ; vinegar and water ; solution of sulphate, or of perchloride of iron ; oil of turpentine ; castor oil ; decoction of aloes ; or infusion of senna. As abundance of mucus in the intestines forma a convenient nidus for the growth of worms, anything that diminishes this tends to prevent their occurrence ; and for this purpose, preparations of iron and bitter tonics are useful. T. Laudeb Bbukton. ANTHEAX (ivSpal, a coal).— A synonym for carbuncle, and for malignant pustule. See Carbottcle; and PusxtJiB, Malignant. ANTIDOTE (&»t1, against, and 5«»,tu, I give.) — ^Definition. — An antidote is any remedy which, by its physical or its chemical effect upon a poison, or in both ways, is capable of ANTIPEHIODICS. 67 preventing or counteracting the physiological effects of that substance. {See Antaqonism.) Sometimes, however, the term is used in a more comprehensive sense, so as to include the gene- ral treatment of a person affected by a particular poison. Thus, in poisoning by opium, the use of the stomach-pump, enforced exertion, chafing the limbs, and artificial respiration may be in- cluded in the general antidotal treatment. Modes of Action, and Application. — ^Most antidotal substances form with the poison insol- uble or innocuous compounds. Without at- tempting to give a complete list, the following are examples of the more common poisons and their respective antidotes: — (1) Arsenioits acid: hydrated peroxide of ' iron, or light magnesia ; (2) hydrocyanic acid: newly precipitated oxide of iron with an alkaline carbonate ; (3) otcalio acid: chalk, common whiting, or magnesia sus- pended in water; (4) tartajr emetic: tannin, catechu, or other vegetable astringents ; (5) ace- tate of lead : sulphate of magnesia, or the phos- phates of soda and magnesia ; (6) caustic potash : dilute acetic acid, fixed oils, lemon juice ; (7) corrosive sublimate : albumen, white of egg, flour, or milk; (8) mineral adds: chalk, common whiting, plaster from the walls or coiling, or carbonate of magnesia; (9) chloride of zinc: albumen, milk, or carbonate of soda. Vegetable poisons cannot thus be counter- acted. If they have been taken in the form of seeds, leaves, or roots, the proper course is to remove them from the stomach or bowels as soon as possible by emetics and purgatives, and at the same time to sustain the flagging strength of the patient by the administration of stimulants. On the other hand, if the alka- loid has been taken, it is so soon absorbed that emetics and purgatives are of little avail, or may even be injurious. In these circum- stances we must rely on the administration of the physiological antagonist of the poison (such as chloral hydrate in the case of strychnia- poisoning), and on supporting the strength of the patient. The following are the best antidotes to the vegetable poisons most frequently met with : — (1) aconite root : emetic of sulphate of zinc and stimulants; (2) belladonna leaves or root: emetic of sulphate of zinc, ammonia, stimulants, and after some time an active pur- gative; (3) digitalis: emetics, stimulants, and the maintenance of the recumbent position ; (4) hyos- cyamus leaves: emetics and stimulants : (S) hydro- chlorate or meconate of morphia, or any of the preparations of opium,: emetic of sulphate of zinc, external stimulation by waimth, turpentine or camphor liniments, enforced exertion, artificial respiration, and small repeated doses of sulphate of atropia ; (6) chloral-hydi^ate : the same as for opium; (7) strychnia or nux vomica: animal charcoal suspended in water, repeated laige doses of chloral-hydrate, or chloroform. See Poisons. John G. M'KE>rDp,icK. ANTIMOlfT, Poisoning by. &eTAETAji Emetic, Poisoning by. ANTIPEKIODIOS. — Definition.— Medi- cines which prevent or relieve the paroxysms of certain diseases which exhibit a periodic character. 58 ANTIPERIODICa. EucMEEATioN. — The chief antrperiodica arc : —Cinchona-bark and its alkaloids— Quinine, Cinchonine, Quinidine, and Cinchonidine ; Be- beera-bark and its active piineiple, Bebeerin; Salicin, Salicylic Acid and its salts ; Eucalyptus ; globulus ; and Arsenic. Action. — The mode of action of antiperiodics is at present unknoTro. Uses. — Cinchona, and still more quinine, is almost a specific in the treatment of intermit- tent fevers, periodic head-aches, neuralgias, and other affections caused by malaria./ Though less certain in its action than in intermittent fevers, quinine is also the best remedy in the remittent fevers of the tropics, in which, however, it must be given in very large doses. The other alkaloids of cinchona have a similar action to that of quinine, but they are not so powerful. Bebeerin is only about one-third as powerful, and is by no means so certain; and the same remark applies to the other remedies enumerated. In some cases of ague and other intermittent affections arsenic proves successful when qui- nine feils. Emetics and purgatives are useful auxiliaries to quinine in the treatment of ague, and are employed alone for the cure of this disease in some parts of the world where quinine is not available, T. Latjdeb Beunton. ANTIPHLOGISTIC (avrX, against, and ip\4yu, 1 burn).-^A term for any method of treatment that is intended to counteract inflam- mation and its accompanying constitutional disturbance. AWTIFTBETICS (cii^l, against, and wvperhs, a fever). — Definition. — Medicines which reduce the temperature in fever. Encmebation. — The principal agents used as antipyretics are — Cold Baths, Cold Applications, Ice ; Diaphoretics ; Alcohol ; Chloral ; Quinine ; Salicylic Acid and its salts ; Eucalyptol ; Essen- tial Oils; Aconite; Digitalis; Veratria; Pur- gatives ; and Venesection. Action. — The temperature of the body may be reduced, either by increasing the abstraction of heat, or by lessening its production. The direct application of cold, by means of baths, affusion, or sponging, or by enveloping the body in sheets wrung out of cold water, is the most powerful, and rapid means of abstracting heat. But the loss of heat which constantly occurs, even in health, by evaporation of the sweat, and the radiation and conduction of heat from the skin, may be increased by the use of diapho- retics, such as salts of potash, preparations of antimony, or acetate of ammonia; or by such medicines as dilate the cutaneous vessels, so as to allow the heated blood to circulate freely through them, and to become cooled by. the ex- ternal media surrounding the skin. Alcohol, in the form either of vrine or spirits, and chloral, have an action of this sort, though alcohol also influences the production of heat. Alcohol, quinine, salicylic acid and its salts, eucalyptol, and essential oils lessen the production of heat within the body, probably by diminishing oxida- tion of the tissues. (See Alcohol.) Aconite, digitalis, and veratria reduce the temperature, .but their mode of action is not precisely ascer- tained. , . ,, Uses.— Antipyretics act much more powertully in reducing the temperature of the body in fever than they do in. health. , They may be used when the temperature has risen either from ex- posure to a high external temperature, as in thermal fever; in consequence of inflammation, as in pneumonia, or pericarditis ; or in specific fevers, as acute rheumatism, typhus, and scarla- tina; The most rapid and powerful antipjn:etic remedies are cold biths ; next probably come large doses of salicylic acid and quinine. The latter seems to act very efficiently in thormia fever when injected subcutaneousjy. T. Latjdbe Bkunton. ANTISEPTICS. — Antiputresoents (lavl, against, and o-jjirTiKis, putrefying). Definition. — An antiseptic is a substance which p]'event.s or retards putrefaction, that is, the decomposition of animal or vegetable bodies accompanied by the evolution of offensive gases. The putrefactive change occurs only in dead matter, and requires the presence of water, heat, and a ferment. That there is no putrefac- . tionin the absence of water is obvious, for bodies, such as albumin and blood, which in the moist state are highly susceptible of putrefaction, may be kept for an indefinite time without change if they be perfectly dry. Heat also has an im- portant influence on putrefaction. At very low temperatures the putrefactive change ceases, while elevated temperatures, such as prevail in tropical climates, are favourable to it. An addi- tional element besides heat and moisture is, how- ever, required, and the opinion generally accepted at present is, that this consists of minute vital organisms, which in some way excite putrefac- tive decomposition. Mode of Action. — The substances used as antiseptics act either directly on the bodies in which putrefaction is occurring or might occur, forming with them combinations that are not susceptible of the decomposing action of a fer- ment ; or they act indirectly, by destroying the vitality or otherwise preventing the develop- ment and propagation of the organisms of which the ferment is composed. In this respect anti- septics are distinguished from disinfeetanis, the action of the latter being directed only towards the exciting causes and offensive or deleterious products of a class of changes which are them- selves more comprehensive than those implied by the term putrefaction. Enttmeeation. — There are numerous chemical agents possessing antiseptic properties, the chief of these including Chlorine, Sulphurous Acid, Nitric Oxide.and Peroxide of-Nitrogen, as gases ; Carbolic Acid, Creasote, Benzol, Sulphites and Hyposulphites, and the Hypochlorites, which emit vapours at common temperatures ; Chromic, Boric, Tannic, and Salicylic acids. Permanganate of Potash, Sulphocarbolates, Chlorate of Potash, Chloride of Zinc, and Charcoal, from which no vapour is emitted. Uses. — 1. In therapeutic practice antiseptics are chiefly employed in the treatment of surgical operations and open wounds, to prevent the occur- rence of putrefactive decomporation. Those antise p- ANTISEPTICS. tics are best suited for this purpose which, acting efficiently on the ferment, have little action^ and no injurious effect, on the parts in which the healing process is going on. Gases, except in solution, cannot be readily used, as it would be necessary to enclose the substance to be preserved in an air-tight vessel containing the gas. The volatile antiseptics which slowly emit a vapour have been preferred to those which emit no vapour, although among the latter salicylic and boric acids, being devoid of any irritating pro- perties when applied to inflamed surfaces, would on this account present a marked advantage. Carbolic acid has been used with success, a solution in water containing one part of the crystallised acid in from forty to one hundred parts of water being applied as a lotion, and also in the form of spray, diffiised through the atmosphere during a surgical operation or the dressing of a wound. The carbolic acid solution may also be used on lint or cotton-wool for covering the affected part. Antiseptic gauze for a similar purpose may be made by adding one part of crystallised carbolic acid to five parts of common resin and seven parts of paraffin melted together, and applying the compound to coarse muslin, so as to form a thin coating of the plaster over the gauze, which, when it has hardened, is used for covering the parts to be protected. Professor Lister has also re- commended a boric acid dressing for lodent ulcers, which is composed of boric acid and white wax, each one part^ paraffin and almond oil each two parts. The boric acid and oil are added to the melted wax and paraffin, and the whole stirred in a mortar until it thickens, then set aside to cool and harden^ after which it is to be rubbed in the mortar until it acquires the consistence of an ointment. This is thinly spread on fine rag and applied to the wound. The oil separates, and is absorbed by lint or rag placed over the dressing, while a firm plaster remains attached to the skin, which is easily removed when, necessary. Salicylic acid may be substituted in this dressing for the boric acid. In some cases salicylic acid is applied alone, by. merely sprinkling it in fine powder over the part affected. Its very slight solubility in water presents an obstacle to its use in solution, un- less something be added to render it more solu- ble ; and borax, which is itself a good antiseptic, may be used for that purpose. Ooe drachm of salicylic acid, two drachms of borax^ and half an ounce of glycerine, with three ounces of water, form, if aided with- a little heat, a clear solution which may be used as an antiseptic lotion. 2. In medical practice aintiseptics are also em- ployed, either as local applications or as internal remedies. Those which are chiefly available include creasote, carbolic acid, the snlphoca^bo- lates, sulphurous acid, the sulphites or hypo- sulphites, chlorine water, permanganate of potash, borax or boric acid, chlorate of potash, charcoal, salicylic acid, and thymol. They are principally used . for the prevention and treat- ment of infectious fevers ; and in low forms of ulceration of the throat. 3. In usihg antiseptics for the preservation ot anatomical specimens, a wider range of chemical ageuts may be tAken, and a selection made of ANTISEPTIC TREATMENT. S9 substances that would be inapplicable in the treatment of the living subject. ArsenioUs acid, corrosive sublimate, or chloride of zinc in solution are of service for this purpose, and chromic acid, even when diluted with ■from five hundred to one thousand parts of water, possesses the pro- perty of preserving animal matter from decom- position, as also does a solution of one part of borax in forty parts of water. Besides the more powerful antiseptics noticed, others of a milder nature, such as common salt, nitre, and sugar, are used for preserving; articles of food ; while alcohol and glycerine are employed for the preservation of animal and vegetable sub- stances as specimens. T. Bedwood. ANTISEPTIC TEEATMEKT is treat- ment directed against putrefaction, or rather, as now generally understood, against the develop- ment of fermentative organisms. 1. Iii SuBGBBY, the employment, of the. anti- septic method is based upon the theory which attri- butes putrefaction and its consequences to minute organisms (bacteria, &c.) derived from without. , The tieatnxent yields the most satisfactory re- sults when it is so employed as to prevent,, rather than to attempt to correct putrefaction. To. ob- tain these results the surgeon must have unbroken skin to operate upon, or the wound must have been so recently inflicted that there has not been time or opportunity for the septic organisms to get beyond the reach of the antiseptic which he employs. Hence there must always be a per-^ centaga of failures in the treatment of compound fractures and large lacerated and contused wounds, owing to the amount of septic air aijd dirt carried into .the recesses of the wounds between the time of the injury and the commencement of the treat- ment. In the event of putrefaction occurring iu such a case, antiseptic dressings should be con- tinued, but the question of operative interference mu^t be determined according to the ordinary principles of surgery. Putrid ulcers and super- ficial wounds may certainly he rendered aseptic by suitable means, and so probably may cavities laid open during excision or amputation ; but the attempt to correct putrefaction in deep sinuses; such as those connected with caries of vertebrae, is hopeless, though by appropriate dressings the putrid emanations may be rendered less noxious to the patient and those about him. The antiseptics which have been found most smtable are carbolic acid, boric acid, chloride of zinc, and salicylic acid. Carbolic acid is the antiseptic most generally useful. A solution of one part to. twenty ot water is employed to purify the. skin of the part to; be operated upon, the sponges, instruments, &c. A solution of one part to forty is used for washing sponges during, an operation, for the hands of the surgeon and assistants, and for the changing of dressings. The volatility of carbolic acid renders it invaluable for dressing hollow wounds and abscesses. It is the active constituent of the ordinary dressing — antiseptic gauze, which is applied in eight layers, of size proportioned to the expected quantity of dis- charge, a 'piece of reliable thin mackintosh cloth (hat lining) being interposed beneath the outer layer of gauze; this serves to prevent the dia- 80 ANTISEPTIC TREATMENT. charge from soaking directly through the central part of the dressing, thereby washing out the stored up acid, and allowing the direct access of putrefactive organisms to the cavity. Disastrous consequences have followed from a defect in the mackintosh. A small portion of gauze wrung out of the one-to-forty carbolic acid solution is applied over the wound before the ordinary eight-fold dressing, so as to prevent possible mischief from putrefactive organisms accident- ally adherent to the inner layer of the gauze, which might not otherwise be destroyed, owing to the slight volatility, at the ordinary tempera- ture of the atmosphere, of the acid stored in the gauze. The gauze is also useful, on account of its antiseptic properties, as a bandage in retrac- tion of the soft parts in stumps, and in any case in which free discharge is expected. In addition to other measures, there must be an antiseptic atmosphere provided, so that the air which gains access to the wound or abscess may be innocuous. This is secured by means of a spray of one-to-forty carbolic acid solution, for the production of which Lister's portable steam apparatus may be used. ■ "When the spray is suspended during an operation or the changing of a dressing, the wound is covered with a piece of sound calico moistened with the same solution. Of course superficial sores and wounds require neither spray nor guard. Cicatrisation is promoted by interposing between the healing parts and the antiseptic agent an impervious, unirritating protective layer, composed of thin oil-silk varnished with copal and then coated with a layer of dextrine, which allows the oil-silk to be uniformly wetted by the antiseptic solution into which it is dipped at the moment of application. The antiseptic dressing proper must extend a considerable dis- tance beyond the protective layer, so as to prevent the access of putrefactive organisms beneath it. Lint soaked in a one-to-ten solution of car- bolic acid in olive oil is used as a dressing for abscesses near the anus, and occasionally as a stufBng for cavities. A one-to-twenty oily solu- tion is smeared upon urethral instruments to pre- vent putridity of urine and its consequent evils.' Bono acid is a powerful antiseptic, but its non-volatility prevents its being used for the dressing of hollow wounds and in the form of spray. It is bland and unirritating as compared with carbolic acid, and is therefore particularly serviceable as a dressing for superficial wounds and sores. It is employed in the form of a satu- rated watery solution; as an ointment, in the proportion of one to six ; and as boric lint, which contains about half its weight of the acid. Chloride of xino has the remarkable property of producing such an effect upon the tissues of a recent wound, that when applied once as a watery solution of about forty grains to the ounce, the cut surface, though not presenting any visible slough, is rendered incapable of putrefaction for two or three days, even when exposed to the * Cystitis, thus complicated with putridity of the iirine, due to infection by cathetei-s, may often be benefited by WEmhing out the bladder with sciution of borio acid. This complication of coniEe never arises when the instra- monts have beeu oarbolised from the commencement of the tTeatmcnt. influence of septic material. The patient is thus tided over the dangerous period preceding sup- puration, during which the divided tissues are most prone to inflammation and the absorption of septic products. Hence this agent, though not adapted for general use, is of the highest value when it is impossible to exclude septic organisms in the after-treatment, as, for ex- ample, after the removal of tumours of the jaws, in operations about the anus, and in ampu- tations or excisions in parts affected with putrid sinuses, which should first be scraped out with the sharp spoon. Sometimes a peculiar, disagreeable odour is observed on removing an antiseptic gauze dress- ing which has been applied for several days, especially to regions which have naturally a powerful odour, as the axiUa or groin ; and occa- sionally the odorous material is so irritating as to produce actual eczema around the wound. This seems to depend upon a reaction between the discharge or excretion and some ingredient of the gauze. Salicylic acid has the power of pre- venting this reaction, or, at anj' rate, of obviating or remedying its bad effects, if a little of the acid is smeared upon the protective or upon the inner layer of gauze. Salicylic acid has been introduced as an independent dressing by Prof. Thiersch, but has been found by Prof. Lister to be inferior to carbolic acid for the destruction of bacteria, though very efficient in preventing fermentations. Chloral, thymol, and Eucalyptol are used as anti- septics. Mr. Lister recommends gauze containing oil of Eucalyptus when symptoms of poisoning follow the use of the ordinary gauze dressing. Prepared antiseptic catgut is employed for arresting arterial haemorrhage. Chassaignac's drainage-tubing is introduced to prevent tension after the opening of an abscess, or after the application of antiseptics to the raw surface of a hollow wound. Carbolised silk sutures are used, as they are not liable to catch in the dressings. 2. In Medicine, antiseptic treatment is based on the hypothesis that infectious and contagious diseases are caused by the presence and multipli- cation in the human organism of minute para- sites, termed microzymes, microphytes, micro- cocci, &e. _ On this assumption, special remedies are administered for the purpose of destroying these minute organisms, or of rendering the blood and other tissues incapable of sustaining them. The treatment further aims at preventing the spread of these diseases by the prophylactic administration of antiseptic remedies to persons who are compelled to remain in infected places. At present a definite relation would seem to have been made out between specific microphytes and cow-pox, sheep-pox, splenic fever, and re- lapsing fever respectively ; whilst a similar con- nection has been so far supported by observations in the case of measles, scarlatina, diphtheria, enteric fever, and erysipelas ; but much remains to be done before the true relation between microphytes and infectious diseases can he esta- bhshed. Seeing that antiseptic therapeutics depends on an unestablished eetiology, it cannot be expected to be in a very advanced condition ; accordingly there is at present but little that is settled or satisfactory to be said. The tulphUet ANTISEPTIC TEEATMENT. mA hyposulphites, introduced by Professor PoUi in 1867, have been freely given in zymotic diseases in twenty-grain doses every three or four hours, and with apparently good efl'ect. Carbolic add is also said to have been success- fully used in diphtheria and in intermittent and eruptive fevers, in doses of from one to five minims or more. The sulphocarbolaies, introduced by Dr. San- som in 1867, have been used with success in many diseases. They produce very little phy- siological effect, and seem to deserve increased atteuti-tn. Dr. Brakeniidge believed that he found sulphocarbolate of soda remarkably bene- ficial in an epidemic of , scarlatina in 1875. Patients under ten years were given five grains, and those above that age twenty grains, every two hours. Also, according to this authority, the prophylactic effect of ten-grain doses three times a day was very striking. Thymol and salicylic acid have also risen into fevour, owing to their powerful antiseptic effects being associated with comparative physiological inertness. Sarcinous dyspepsia is greatly relieved and sometimes cured by Eussmaul's method of wash- ing out the stomach with solution of perman- ganate of potash, or some other antiseptic. Keference must be made to solution of per- manganate of potash, solution of carbolic acid, glycerine of borax or a preparation of boric acid of the same strength, sulphurous acid, and chlorate of potash, as applications to the throat in such diseases as diphtheria and scarlatinal tonsillitis, or in any form of sloughy ulceration of this part. To these may be added a five- grain solution of sulphate of quinine. John Bishop. AM-TISPASMODIOS (oktI, against, and airdafM, a spasm). — Definition. — Medicines which prevent or allay spasm. Enumeration. — Antispasmodics may be ar- ranged in groups as follows : — Valerian,, Vale- rianic Acid and its salts ; Musk, Castor, Assafffitida, Sumbul and Galbanum, Camphor, Brominated Camphor, Oil of Amber ; Ammonia and its Carbonate ; Alcohol, Ether, Acetic Ether, Chloroform, Nitrite of Amyl; Bromide of Po- tassium, Bromide of Ammonium ; Conium, Lobe- lia, Opium, Gelseminum, Indian Hemp, Bella- donna, Stramonium; and the Essential Oils. As adjuvants may be mentioned— Cold Baths, moderate Exercise, Eriction, Heat, and Mois- ture ; and also Quinine, Arsenic, Zinc,, and Silver. Action. — Certain nerves and nerve-centres, when excited, produce contraction of volun- tary or involuntary muscular fibres; other nerves and centres arrest movements; and by the combined action of these two systems the motions of the various contractile structures in the body are regulated, and subordinated to the require- ments of the organism as a whole. Excessive contraction or spasm of one part of the body may therefore arise either from excessive action of the motor, or deficient action of the inhibitory centres. Spasm may affect the involuntary mus- cular fibres of the intestines— as in colic ; of the vessels— as in some forms of headache, and in faso-motor neurcses of the uterus and bladder : ANUS, DISEASES OF. CI single voluntary muscles, or groups of muscles — as in various forms of cramp : or the muscular system generally— as in tetanus, epilepsy, and hysteria. Antispasmodics may act by lessening the irritability of motor centres, as, for example, bromide of potassium and conium ; or by stimu- lating those portions of the nervous system which restrain and co-ordinate movements, as alcohol probably does. There are no direct experiments to show the action of antispasmodics on the in- hibitory centres ; but it seems probable that they have such an action, although it may rot be con- fined to these parts alone. Thus small doses of alcohol and ether, which stimulate the nervous system generally, and usually increase motor activity, will restrain and co-ordinate excessive muscular action, as in colic, nervous agitation, trembling, and hysteria. It is at present im- possible to localize the part of the nervous system affected by valerian, assafoetida, and other drugs of this class.i As spasms occur when the nervous system is deficient in power, nervine and general tonics, such as quinine, zinc, and iron, are often found to be useful adjuvants. Uses. — In such- convulsive diseases as epi- lepsy, laryngismus stridulus, and infantile con- vulsions, bromide of potassium is the most powerful antispasmodic ; in hysteria — valerian, assafoetida, and the bromides ; in chorea — arse- nic, conium, copper, and zinc ; in spasmodic asthma — lobelia and stramonium ; in spasm of the blood-vessels — nitrite of amyl. In all spasmodic affections, cold baths or sponging, exposure to sunlight, moderate exercise, and a plain but nutritious diet should be employed ; and late hours, a close atmosphere, exhausting emotions, or excessive bodily or mental wort should be avoided. T. Laudek Beunton. AITTJEIA. — ^Absence of urination, whether from suppression or retention of urine. See MicirEiTioN, Disorders of. _ ANUS, Diseases of. — The prmcipal affec- tions of this part are Congenital Abnormalities ; Epithelioma; Irritable Sphincter Ani; Irritable Ulcer; Prolapsus; Prurigo; Tumours and Ex- crescences. l.CongenitalAbnormalities(^ They usually require, however, to bo removed by excision, the quickest and most effectual mode of treatment. Astringent lotions must afterwards be used to prevent the reproduc- tion of the warts. Flattened growths from the skin, commonly called mucous tubercles, a secon- dary result of syphilis, are liable to occur around the anus, They yield readily to the local appli- cation of mercury and specific general treatment. T. B. CUTELINO. AITZSIETAS. — Anxiety or distress, whether subjectively felt, or expressed in the features, attitude, or general behaviour. The term is also specially associated with a peculiar sensa- tion experienced in the region of the heart. See PejecoKdiai. Anxiett. AOB.TA, Diseases of. — The diseases to which the aorta is liable may be thus considered : — 1. Aortitis, Acute and Chronic; 2. Atheroma; 3. Primary Fatty Degeneration; 4. Primary Calcification ; 6. Coarctation ; 6. Simple Dila- tation ; and 7. Aneurism. 1. Aortitis. — Acute aortitis is exceedingly rare. It may result from the direct irritation of an ■ atheromatous aorta by a thrombus or an embolus, in persons of gouty diathesis ; but has never been observed as an extension of acute endocarditis. The morbid changes' consist in hypersemia, with thickening and softening of the coats of the vessel, and deposit of fibrin upon its internal surface. The ascending portion of the arch is the part most frequently affected. The symptoms are acute substernal pain with oppression, palpitation, quick and feeble pulse, and elevated temperature. "With these symptoms may be_ associated a harsh systolic murmur, originating at the seat of inflammation, and transmitted to a distant point of the aorta. Svb-acute and Chronic Aortitis. — These are the usual forms of inflammation of the aorta. The disease may be general, arising from a blood- dyscrasia such as gout, from pyaemia, or from the_ various septic agents; but it is usually limited to a definite portion of the vasculair sur- face, being the result of local irritation. JEtioloqy. — Excessive and continued strain of the vascular walls is, according to its degree, the most frequent cause of sub-acute and chronic aor- titis. Hehee, the portion of the arterial syetom AORTA, DISEASES OF. 68 most directly affected by the impiilse of the left ventricle, namely, the arch of the aorta, is that in which inflammatory irritation is first, and often exclusively, exhibited. Labour of any kind re- qniring great and repeated muscular effort whilst the breath is held, must necessarily subject the aorta to extreme tension, partly through the ob- struction arising &om the pressure of the con- tracted muscles upon the subjacent arteries, and partly from the back-preSsure of the distended veins. Hence, sledgers, rammers, ship-porters, &c., are those who most frequently suffer from the effects of aortitis. As a necessary result of such efforts the left ventricle soon becomes hy- pertrophied, and the evils arising from vascular tension are thereby proportionately increased. Furthermore, the free use of alcoholic stimulants, in which such labourers habitually indulge, con- tributes to the same result by imparting irritant properties to the blood. The British soldier has been especially liable to the evils above sketched, owing U) a vicious system of forced drill with a breathing-capacity diminished by faulty con- struction of his dress and accoutrements.' Anatomical Chahacters. — Sub-acute aortitis occurs in disseminated patches, and involves all the coats of the vessel. These are infiltrated with oxudation-cells at an early period ; become soft and tumid, assuming a bluish-white tint; and, owing to loss of normal elasticity, project outwards, thus causing unevenness or pitting of the internal surface. In the aorta the inflammation is usually primary; but exceptionally it may be produced by the mechanical irritation of an embolus derived from an inflamed focus. In- flammatory softening is a frequent cause of aneurism at all periods of life ; and in the young it is the ordinary precursor of that disease. In chronic aortitis, which is the most common form of the disease, the internal coat is alone in- volved. The outer portion of the intima exhibits the result of irritation in the abundant production of new cells. These cells occupy the fttsiform spaces betweenits lamellse,and, gradually distend- ing them, ultimately project the internal and un- affected portion of the tunic into the lumen of the vessel. The prominence so caused is com- paratively solid, presents a faint bluish tint, and constitutes the condition described as ' flbroid or semi-cartilaginous thickening.' The inflamma- tory prciduct is prone' to undergo fatty de- generation, and the consecutive change called atheroma. 2. Atheroma. — This morbid condition is most common in the first portion of the aorta. Anatomical Charaoteks. — Atheroma com- mences with inflammatory overgrowth by multi- plication of the cells of the outer portion of the intima, as described in a preceding paragraph. The neoplasts, from their situation,' readily un- dergo fatty change an4 caseation ; the septa of unaltered tissue intervening between them soon lose their vitality and are absorbed ; and the disease thus spreads, whilst it advances through the same agency towards the internal surface of the vessel. Examined microscopically, athe. ' Also by the constrained and fixed' position In which the walls of the chest are placed ivhen the shoulders are forced backwards, with the view of piuduoing the ap- pearance of an expanded chest.— Ed. romatouB mattjr is found te consist of &t granules, crystals of cholesterine, and tissue- debris. At an early stage collections of this matter may undergo licfuefaction, and, projecting into the vessel, covered only by a thin layer of the unaltered intima, constitute a so-called athero- matotis abscess. Should this establish a com- munication ■with the artery, an atheromatous ■ulcer will be the result^ and, consecutively, a false aneurism. In the most advanced stage of atheromatous change many patches undergo- calcification by deposit of lime-salts in the altered cells. The calcareous lamellae so formedy being concentric with the vessel, and contracting by loss of their liquid constituents, may erode the intima by their sharp edges. From the injury thus inflicted aneurism may arise, or interstitial thrombosis, by which the vessel may be entirely blocked and gangrene of the extremities produced. In con sequence of the foregoing changes the vessel loses its elasticity and becomes dilated ; its in- ternal surface is mottled with yellow or fawn- coloured patches of various sizes, being also rough, spiculated, and fissured; and thus- the condition described by Virchow under the name of Endarteritis Ckrotiica Deformans is established. The uric-acid and oxalic-acid diatheses favour these changes, not only by stimulating the minute arteries to contract, and so raising the blood-pres- sure in the larger vessels, but likewise by fur- nishing material for oi-etifioation. The subject* of constitutional syphilis are liable to ' ulcerated steatomatous ' (atheromatous) changes of the intima. 3. Primary Fatty Degeneration. — Virchow has described, under the name of fatty erosion, a form of fatty degeneration of the cells of the internal coat,unprec6ded by infiammation, com- mencing on the free surface, and gradually ex- tending outwurds. The internal surface of the vessel is marbled with minute yellow dots, which are groups of fatty cells ; these undergo lique- faction ; and disintegration of the internal coat, followed by aneurism, is the usual result. 4. Primary Oaloifloatiou. — Exceptionally^ in the distant pbrtioris • of the aorta the muscular fibre-cells of the middle coat are liable to calcifi- cation, as a remote result of endarteritis. Ovring tothetransversearrangementof the calcified cells, fisSuring of the middle coat under the pressure of the blood-current, and dissecting aneurism, are ordinary results of this change. Finally, the entire middle coat, and even all three coats of the artery, may be infiltrated with lime-salts as a primary change. This is most probably due to precipitation of these salts from the congested vasa vasorum, in consequence of the escape of their ordinary solvent, carbonic acid. 5. Coarctation or Stenosis. — This condition niay be either congenital or acquired. Congenital stenosis of the aorta is most fre- quently located at the point of junction of the ducitis arteriosus, and is of very 'limited extent ; in many cases presenting the appearance of a linear constriction, or of a perforated diaphragm. Ill a fe-w examples, the vessel, at the seat of corftraction, has been entirely closed and con- verted into a li^alnentous cord. On the cardiac side of the constriction the aorta is dilated, and 64 AOETA, DISEASES OF. often thickened and atheromatous, ■whilst on tho distal side it is reduced in calibre as far as the junction of the collateral vessels. Congenital stenosis of the aorta is compatible with life of moderate duration. In twenty-four out of thirty- eight cases analysed by Dr. Peacock the age at- tained varied from twenty-one to fifty years. The diagnosis of the condition rests mainly on dispro- portionate pulsation of the arteries arising- from the aorta on the cardiac, as contrasted with those on the peripheral side of the obstruction ; and on the enlargement of the collateral vessels, namely, the transverse cervical, internal mammary, and in- tercostals. The ordinary consequences are ex- hibited in dilated hypertrophy of the left ventricle, andinadequacy of the aortic valves. Death usually occurs from progressive debility and failure of the left ventricle ; from pulmonary congestion ; or from dissecting aneurism of the ascending por- tion of the arch. Congenital stenosis of the entire arch may result from imperfection of the inter-ventricular septum or patency of the fora- men ovale allowing the blood to take an ex- ceptional course. In the acquired form, stenosis of the aorta at any portion of its course may result from in- flammatory thickening or calcareous change of the coats of the vessel, followed by thrombosis ; or it may follow the natural cure of an aneurism. The aorta may be much reduced in calibre without being disproportionately narrowed. Such will be its condition in connection with mitral in- adequacy in early childhood, should the patient survive a few years. In such cases the left ventricle will have become dilated and hyper- trophied, and a marked disproportion will be observed between the force of cardiac and that of radial pulsation. This circumstance, taken in conjunction with the age of the patient, the existence of disease at the mitral orifice, and hypertrophy of the left ventricle, would warrant the positive diagnosis of narrowing of the aorta. 6. Simple Dilatation of the aorta consists in a uniform enlargement of the vessel or of a por- tion of it, from impairment or loss of its normal elasticity ; and depends primarily upon arterial obstruction or resistance beyond its seat, and directly upon consecutive hypertrophy of the left ventricle. The continued tension, to which the walls of the aorta are subjected between these two opposing forces, necessarily leads to progressive impairment of nutrition and loss of elasticity in its middle coat. The immediate consequence of this change is exhibited in fur- ther hypertrophy of the left ventricle ; and its remote efiects in still further impairment of nutrition and deterioration of tissue in the vas- cular tunics, through the increased tension to which they are now exposed. No elementary change of structure is, however, discoverable. Simple dilatation of the aorta commences in the ascending portion of the arch, and to this it is usually limited ; but it occasionally extends into the transverse portion. The other portions of the vessel are never dilated, except in association with atheromatous change. The condition under notice is manifestly in close relationship with inflammatory irritation of the vessel. It has, however, a distinct pathological existence, ana- logous to that of the early stage of vesicular em- physema of the lung. No morbid results, vriti a single exception, are directly traceable to simple dilatation of the aorta. But, should the dilatation extend into the trans- verse portion of the arch, and engage especially its superior wall, the primary branches may- become tortuous, and exhibit abnormal pulsation in the neck, simulating aneurism. In a note- worthy example observed by the writer the existence of this pulsation on both sides of the neck, and the facility with which it was arrested by forcibly extending the neck and shoulders, and so unbending the vessels, sufficed to establish the diagnosis. Tortuosity of the cervical arteries, dependent upon a local dilata- tion of the aorta, may be confined to one side of the neck. Simple dilatation of the aorta most frequently occurs in connection with the contracted or gran- ular form of chronic renal disease. It may, however, likewise arise from simple functional hypertrophy of the left ventricle dependent upon habitual vascular excitement ; or from di- lated hypertrophy consecutive to ihadequacy of the aortic valves. 7. Aneurism. — .SItioiogt and Pathology. — Aneurism of the aorta is essenl ially a disease of the middle period of life. Of ninety-two cases ob- served or analysed by the writer, sixty occurred between the ages of thirty and fifty years ; twelve over fifty ; and five under thirty years. Thus, whilst deterioration of the arterial coats as typified in atheroma is most common after the ago of sixty, one of its ordinary conseqaences, aneurism, belongs to an earlier period of life. The apparent discrepancy may be explained by the more frequent employment of men under fifty in severe labour, and their greater capacity for extreme muscular effort then than later in life, the condition of the arterial wall which fa- vours aneurism having been already established. Aortic aneurism is more common amongst males than females in the proportion of about 8 : 1 — a difference no doubt due to the more active and laborious habits of the male sex. Soldiers, me- chanics, and porters suffer from it in larger proportion than those of other callings ; and in most instances the first symptoms of aneurism of the aorta may be traced to a great muscular effort involving vascular strain, or to a severe shock or blow, causing a direct contusion. Aneurism of the aorta is always consecutive to disease of its coats. Infiammatory softening, atheroma, and calcification are the usual ante- cedent conditions, and in exceptional instances primary fatty or calcific transformation of the internal and middle coats ; whilst a definite over- strain or a direct contusion of the vessel is fre- quently the immediate cause of the disease. Anatomical Chahacteks. — ^Aortic aneurism may be presented under the following forms, viz., (a) true; (b) false {circumsmhed, and dif- jused or consecutive); (c) dissecting; and \d) varicose. a. True aneurism of the aorta is rare; it may be either fusiform or saccular. It is es- sentially transitional, leading to the false variety of the disease ; and differs from simple dilatation of the aorta only hy its sharp limitation, and by AOETA, DISEASES OF. 65 the existence of inflammatory products in its walls. True aneurism never contains clots, save by incidental thrombosis ; and riirely, as such, attains dimensions capable of producing extrinsic symptoms or signs. It ma.y, however, unlike simple dilatation, be the cause of valvular in- adequacy, and so give rise to a murmur of reflux at the orifice of the aorta. 4. False aneurism is either circumscribed or diffused. Circumscribed false aneurism (or, as it is also termed, false aneurism) is the most common form of the disease in connection with the aorta. It is necessarily confined to a portion of the circumference of the vessel, the yielding of which relieves the remainder from extra ten- sion. Hence, it is usually saccular in general outline ; but, owing to unequal resistance at dif- ferent points of its surface, it may, and commonly does, present one or more secondary prominences. The internal and middle coats are usually broken ■,-^the adventitia supplemented by the surrounding structures more or less condensed, forming the sac. Disintegration of the inner coat, already in a state of atheromatous change by mechanical strain or vascular tension, is ordinarily the im- mediate cause of false aneurism. The irruption of an ' itheromatous abscess ' may also give rise to it ; so likewise may ulceration of the intima from fatty erosion. Rupture of the coats oi the vessel by mechanical strain is usually an- nounced by definite symptoms of the utmost significance, namely, a feeling of something having given way within the chest or abdomen; followed by faintness often amounting to syncope, dyspncea, palpitation, and occasionally hasmopty- sis. These symptoms of shock usually subside within a period of one to two hours, but the patient is thenceforward incapable of his ac- customed exertion, being easily put out of breath, and distressed by excitement or rapid movement, especially that of ascent; there is likewise a fixed pain at some point of the chest, back, or abdomen. A fusiform false aneurism may become ' invaginating ' by abruptly expand- ing and ensheathing the artery at its proximal or distal side, or in both these situations. Diffused false aneurism (or, as it is otherwise called. Diffused aneurism, or Consecutive aneurism) is produced by escape of blood from the artery, and its diffusion to a greater or less extent amongst the surrounding structures, according to their previous condition or anatomical arrange- ment. It may be the result of mechanical violence by strain or shock to the artery in a previously diseased condition ; or of progressive disintegra- tion of the sac of a circumscribed aneurism. In the latter case the diSusion of the extravasated blood is usually limited by antecedent adhesive inflammation of the surrounding parts, where, as in the transverse portion of the arch of the aorta, the position of the aneurism is favourable to that process. A case of this description recently came under the writer's notice; Under ordinary circumstances difiused false aneurism of the . aorta cannot occur within the pericar- dium; owing to the isolation of that portion of the vessel, and the fragile structure of its serous investment. Hence, a yielding of the sac proper in this situation is, in most instances, followed by instant death from haemorrhage into the peri- cardium and paralysis of the heart. In a few recorded cases, owing to previous adhesion of the pericardium, the patients survived rupture of the sac in this situation for several days. Diffiised false aneurism of the abdominal aorta is frequently formed by irruption of blood into the retro-peritoneal tissue, between the layers of the transverse meso-colon or the mesentery, or into the fibrous envelope of the psoas muscle. When the aneurism grows back- wards the sac is quickly eroded by pressure against the vertebrae, the naked and carious surface of which then forms its posterior boundary. Diffu- sion in such cases rarely occurs until the vertebrae are entirely absorbed ; the blood may then escape into the spinal canal, causing general paralysis and immediate death. Diffusion may also occur amongst the muscles and areolar tissue of theloins, or behind the diaphragm into either pleural cavity, usually the left. Any portion of the aorta outside the pericardium may be the seat of diffused false aneurism, but the transverse portion of the arch and the abdominal aorta are the parts most frequently affected. > Consecutive false aneurism, consisting in a primary bulging of all the coats of the artery, the internal and middle coats having subsequently given way, constitutes the ordinary form in which false aneurism originates: it therefore demands no farther notice here. c. Dissecting aneurism, consists in a breach of the internal afid middle coats, and a subsequent detachment of these from the external tunic, by the force of the blood-current, to a variable extent over the length and circumference of the vessel ; or in a splitting of the middle coat by the same agency. This form of aneurism is of two kinds — that -with a single aperture through vrhich the blood enters theabnormal channel and return* to the artery ; and that which exhibits two open- ings, one by ■which the blood escapes from, and another through which it re-enters the vessel. The former is the more usual variety of dissecting aneurism; and it is likewise the more grave, because liable at any moment to terminate fatally by rupture of the external coat. Any portion of the aorta may be the seat of dissecting aneurism ; the ascending part of the arch is most frequently affected, ;and next in the order of frequency comes the abdominal aorta. The primary lesion consists in a transverserent of the internal and middle coats ; when this is close to the heart, the outer or the anterior wall of the vessel is its usual site, and detachment of the tu- nics rarely extends beyond the ascending portion of the arch, and seldom engages more than a limi- ted area of its circumference. In this situation, too, an aperture of re-entrance is rarely formed, the disease usually terminating by rupture of the external coat within the pericardium. "When, on the contrary, the second curve of the arch, or any portion of the aorta beyond this point, is the seat of primary lesion, separation of the coats is usually found to extend along the remainder of the length of the vessel, and over the whole or greater part of its circumference, whilst the blood has re-entered through an opening in one or both common iliac arteries. The establishment of a second aperture of S6 AOETA,. DISEASES OF. sommunication ■with the arteiy is an attempt at 'natural cure;' and when this happens the patieut may survive for many years. Amongst the eccentricities of dissecting aneurism may bo mentioned detachment of the laminated dot from the -vralls of the sac proper, and subsequent es- cape of blood by rupture of the latter ; and sepa- ration of the mucous from the muscular coat of the oesophagus, ■vrith irruption of blood into the stomach. Dissecting and ordinary . false aneu- rism may coexist, the former being usually a consecutive lesion, and the immediate cause of death. i. Varicose or Anastomosing aneurism consists in a direct conununication between an aneurism of the aorta and (a) one of the chambers of the heart ; (6) the pulmonary artery or one of its branches ; or (c) one of the venae cavse or innomi- nate veins. This form of the disease is necessarily consecutivej and usually late as to the period of its development. In the great majority of recorded examples the primary aneurism was connected with the ascending portion of the arch, and in a large number it , arose from one of the sinuses of Valsalva. The communication, with few ex- ceptions, is formed with one of the chambers of the heart, the pulmonary artery, or the descend- ing vena cava. Of the cavities of the heart, the right ventricle is most often implicated; next in order is the right auricle ; then the left ven- tricle ; and lastly the left auricle. The pulmonary artery and the descending cava have been fre- quently involved, as might have been inferred from their close relationship to the ascending aorta ; the innominate veins in fewer instances, and only when the aneurism engaged, the upper portion of the arch. An aneurism of the ab- dominal aorta has communicated with the in- ferior vena cava in a few cases. In the pro- cess of formation of a varicose aneurism of the aorta, the apposed surfaces are agglutinated by adhesive inflammation ; and the composite septum is subsequently eroded by progressive absorption, or suddenly rent by the force of the arterial cur- rent. The immediate effects of communication are engorgement and increased tension of the receiving chamber or vessel; diminished blood-current and vascular tension in the aorta and its branches ; and admixture of arterial with venous blood when the right side of the heart or one of the great veins is the seat of discharge. The special symptoms and signs by which the disease is characterised have direct reference to thesp re- sults. Death has followed most rapidly in those cases in which the aneurism had established a communication with the pulmonary artery or the left auricle. Effects upon the Left FcnincZe.— Hypertrophy, of the left ventricle cannot be regarded as a consequence of aneurism of the aorta. The association, when it exists, is accidental.; hyper- trophy depending upon antecedent or consecutive disease or inadequacy of the aortic or the mitral valves, chronic atheroma of the aorta, granular degeneration of the kidneys, or excessive, fiiUQ- tional activity. STMPTOMS.-7-The. symptoms of , aortic aneu- rism may be discussed under the three Jieads. of (a) Pain; (i) Excentrio Pressure; and (c). Tumour, Pain. — The pafin of aneurism is of two kinds, intrinsic and exttinm. The former is due t«i Subacute inflammation and tension of the sac, and varies with intra-vascular pressure. If is dull, aching, and localised, and promptly allevi- ated by measures which depress the circulation or reduce local tension. Extrinsic pain usually arises from pressure upon adjacent nerves, and may be direct or reflex. This kind of pain has the characters of a, diflFused and aggravated neuralgia, being paroxysmal,, and wandering to a greater or less extent over the back, chest, shoulders, arms, abdomen, and thighs. In the ab- domen, when due to pressure upon the splanchnic nerves or tension of the solar plexus, it is of the most excruciating character. The extrinsic pain of aneurism may be fixed and boring. When of this character, it is usually located in the back; and arises from progressive absorption of the ver» tebrse. - , Exceniric Fressitre-^^Tke parts affected by the pressure of an aneurism, and the symptoms thereby developed, vary according to its situation and the direction of its growth. Parts which are exposed to counter-pressure, or are other- wise fixed, suffer most; whilst those which are flexible or moveable are less injuriously affected. ■ The symptoms have reference to the respective functions of the organs or structures pressed upon ; whilst their severity is in direct proportion to the importance of those functions, and the degree of pressure exercised. Structures sub- jected to the remittent pressure of an aneurism are slowly removed by absorption, but between the Siu: and the resisting surfaceunion has been previously established by adhesive inflammation. Hence the sac itself is at the same time absorbed, and escape of blood will inevitably occur where further resistance is not presented. When serous cavities are laid open by this process, entrance is effected by a rent ; and if the cavity be large, e.ffk the pleura or the peritoneum, death by haemorrhage, almost instantaneous, is the result; in case of irruption into, the pericaxdium or the spinal canal, death occurs with equal rapidity from compression and paralysis of the contained organ. Communication with a mucous canal or with the cutaneous surfiice is effected by a pro- cess of sloughing, and bleeding occurs by ' leak- age,' in variable quantity, and at uncertain inter-' vals, till the slough, is finally detached, when death by copious haemorrhage immediately ensnes. The irruption of an aneurisminto a gland*4uoti such as the ureter or one of the biliary passages, is fatal by obstruction and suspended secretion, the duct audits tributaries having .been blocked by coagulum. Communication with the thoracic duct proves slowly fatal by inanition ; aud when an openingi is effected/ into a vein, a varicose aqeurism, characterised by special symptoms and signs, and of greater or i less gravity according . to its situation,, will be the result. .The S3rmptoms of nerve^pressure vary accord-' ing toi the nerves affected. ; Thus, ipressure upon the roots or branches: of sentienn- nerves ia attended with neuralgic,, twinges or paroxysms referred to the seat of their penipheral distribur tion, and, xhen the pressure is extreme,.?wlth numbness in. the, same situation. Irritatiom-of motor, nerves, is indicated by spasm or parajyeiti AORTA, DISEASES OP. 67 eccording to the degree of pressure, of the muscles supplied by them. Irritation of the cer- Tical sympathetic, or of its eilio-motor roots, is revealed by dilatation of the pupil on the corres- ponding side : or, if the pressure be such as to cause paresis, by contraction of the pupil with ptosis, hyperamia, hypersesthesia, and elevation of tem- perature in the eye and corresponding side of the face. The effects of pressure iipon the pulmonic and cardiac plexuses have been less precisely determined, owing to the difficulty of distinguish- ing the symptoms due to this cause from those which arise ftom direct pressure upon the trachea or bronchi, the great vessels, or the heart, or from structural disease of the heart or the coronary arteries : but that the patoxysms of bronchial spasm and of angina, so often witnessed in connection with aneurism of the arch of the aorta, are in some degree dependent upon pressure on the pulmonary and cardiac nerves, and occasionally are due to it exclusively, the wi'iter entertains no doubt. The symptoms arising from the pressure of an aneurism upon the pneumo- gastric or recurrent nerve of either side have reference to the larynx, and are eminently characteristic. They are of two kinds, according to the degree of pressure ; namely, those due to spasm, and those to paralysis, of the laryngeal muscles on one or both sides. They are presented under the several forms of dysphbnia;, aphonia, stridor, metallic cough, and paroxysmal dyspnoea. The latter is frequently of the most urgent charac- ter, and sometimes is the immediate cause of death. Adjacent organs, feuch as the heart, lungs, liver, and kidneys, are occasionally displaced by an aneurism, the direction being determined by that of the pressure, and in part also by the di- rection in which the organ is moveable. Obstruc- tion or occlusion of adjacent arteries, as indicated by diminished or siippressed pulsation, may like- wise result from the pressure of an aneurism. Pressure on a vein is evidenced by venous stasis distal to the seat of obstruction ; upon the pul- monary artery, by engorgement of the right chambers of the heart and general Venous con- gestion. Obstruction or occlusion of either bron- chus or of one of its primary branches is evi- denced by distress in breathing or shortness of breath; and by diminution or suppression of respiratory sound in the corresponding portion of the lung. Inasmuch as the Symptoms of excentric pressure may be produced by a tumour of any kind, they possess, in reg?ird to aneu- rism, a diagnostic value only correlative to other and more positive evidence of that dis- ease. Tumour.— The tumour formed by an aneurism of the aorta is fixed, smooth, and compressible. It is alternately tense and soft in unison with cardiac pulsation, and is especially characterised by a movement of general and e^uail expansion, synchronous with the impulse of the heart. It is further distinguished'byaremarkable liability to vary in the rate and direction of its growth, retrocession at one point coinciding with enlargement at another ; a new set of symptoms being at the same time developed by its en- croachment upon fresh territory. In the pro- gress of cure the tumour may become solid, incom- pressible, and uneven, by deposition of laminated fibrin within the sac. Physical Signs'.— The physical sign's of aneu- rism of the aorta are those which may be elicited by palpatiori, percussion, and auscultation. They supply the most valuable, and, indeed, the only positive evidence of the disease. Tactile signs. — The tactile sigps of aneurism, impulse, fremitus, otA remittent tension, are con-, tingent on perceptible tumour. The impulse may, be single or double. It is most frequently single, and is then always systolic in rhythm, coinciding approximately with tjie impulse of the. heart. In character the systolic impulse is Reaving and expansile ; and it is diffused, in most in- stances equally, over the entire tumour. It is due to sudden expansion of the sac from active influx of blood during ventricular systole : hence, in those portions of the aorta which are close to the heart, it is synchronous with the apex- pulsation ; but in the descending-thoracic and abdominal aorta perceptibly post-systolic in time. The force of systolic impulse and the expansion of the sac will be directly as the con- tractile power of the left ventricle, and inversely as the deposit of coagulum within the sac. A second and more feeble impulse of diastolic rhythm is occasionally, but much less frequently, exhibited by an aortic aneurism. This is the ' back-stroke,' or ' impulse of arrest ' of authors. It coincides with the first period of ventricular diastole and the second sound of the heart, and is duo to asynch^onism of re- action between the aorta and the sac — that of the latter being notably later, owing to its defective elasticity. The consequence is a sudden arrest to the recoil of the sac by influx from the aorta. Diastolic impulse is therefore emi- nently characteristic of aneurism. Fremitus or thrill is of more frequent occur- rence than diastolic impulse, and, when not communicated Horn the heart, no less distinc- tive of aneurism. It accompanies the systolic iriipulse, and is due to the vibration of a thin sac from an eddy in the current of influx, pro- duced either by a spiculated condition of the orifice, or by a pendent flake of fibrin. Percussion-sound. — The intrinsic percussion^, sound of aortic anetirism is absolutely dull to the extent of the tumour. Posteriorly the dulness is not sufficiently distinguishable from that of the vertebral colunm and muscles to be of positive diagnostic value; whilst laterally and in front, when the tumour is not in actual contact with tbe walls of the thorax or abdo- men, it is modified or masked by the interven- tion of the lung or the intestinaj. canal. Under any circumstances, dulness per se cannot afford positive evidence of aneurism, inasmuch as it may be due to a tumour of any kind, solid or liquid, in the same situation ; but, the presence of a tumour having been dBtenuiiied, the shift- ing of percussion-dul'ness from one point to hnother, or its cessation where it had been, pre- vionisly detected, wbuld be in the highest degree suggestive of aneurism. ' : Acoustic sighs.— These are tone or sound, and murmur. Sound ynthout murmur is of frequent occurrence in aneurisms of the arch, but com- paratively rare in those of the descending. 08 AOETA. DISEASES OF. tboracic and atdominal aorta. It is usually double, corresponding in time to tlie sounds of the heart, but exaggerated, the second aneu- xismal sound being especially intensified. The first sound is occasionally ' splashing,' and bpth are not unfreqnently of a 'booming' quality, —characters no doubt due to the density, rigidity, and grent capacity of the sac. The murmur of aneurism is most frequently single, systolic, and blowing; it is occasionally double (systolic and diastolic) ; and still more rarely single and diastolic. As to quality, the systolic murmur may be accompanied by a musical note, 'cooing,' or shrill, and audible over the whole or only a portion of the tumour, lastly, it may be, and usually is, of a ' buzzing ' character in cases of varicose aneurism. The essential cause of the murmur of aneurism consists in friction of the blood against the orifice, and the production of an eddy or a ' fluid vein ' within the sac. A certain force of ventri- cular contraction is, however, likewise necessary. Eenc9 the not unfrequent coincidence of cessa- tion of murmur with failure of the left ventricle for some time before death. A strongly con- tracting ventricle, a relatively small orifice, a capacious sac, and a liquid state of its contents, supply the most favourable conditions for the production of murmur. The orifice of entrance need not be absolutely narrow ; a large fusiform aneurism, even of the true kind, with rough walls, and containing liquid blood, may yield a loud systolic murmur, as the writer has fre- quently witnessed. A murmur may be absent in an aneurism lined by thick laminse of fibrin through which there is a smooth channel, or in a lateral aneurism communicating by a small orifice with the vessel. DiAOHOsis. — The positive diagnosis of aneu- rism of the aorta may be mode from the exist- ence of a tumour, forming a second centre of pulsation and of sound ; the pulsation being systolic, expansile, and equally diffused over the tumour, accompanied by thrill, and succeeded by a minor pulsation of diastolic rhythm ; whilst the sound, single or double, and accompanied or not by murmur, is always sharp and ringing, and occasionally of a 'booming' quality. The foregoing signs are rarely all associated in the same case. Various other groupings of rational symptoms and signs would be scarcely less con- clusive as to the existence of aneurism of the aorta. General systolic expansion, thrill, dia- stolic impulse, and exaggerated sound, at a point more or less distant from the heart, constitute the most positive signs of the disease. The existence of aneurism of the aorta may be inferred with greater or less confidence from certain symptoms and signs, according to their individnal or correlative value. Even negative signs, if associated with others in themselves of minor significance, may be scarcely less con- clusive than the most positive evidence would be. Thus, for example, suppressed respiration with percussion-resonance on the left side of the chest, dyspncea, haemoptysis, fixed pain in the back, and left intercostal neuralgia — the entrance of a foreign body into the left bronchus and the existence of cancer of the posterior mediastinum having been excluded — would be all but con- clusive as to the existence of aneurism. A foreign body in the bronchus miglit be diag- nosed from the history of a misadventure in swallowing, followed immediately by, dyspncea, haemoptysis, and the special signs of bronchial obstruction, which, in nine cases out of ten, would be on the right side : whilst the diagnosis of mediastinal cancer would rest upon evidence eminently suggestive, namely, the presence of cancerous enlargements in the neck and axilla, and of extreme dulness over the root of the lung, without corresponding pulsation or sound. Finally, aneurism of the aoTta may be, though it Tory rarely is, strictly latent in regard to both symptoms and signs. PkOGNOSIS, DoEATION, and TlSEMTNAnONS. — The prognosis of aortic aneurism is in the highest degree unfavourable. Recovery is, how- ever, under favourable circumstances and ap- propriate treatment, quite within the range of medicine. Numerous examples of cure of aortic aneurism, both thoracic and abdominal, have been lately recorded. The duration of life, in connection with aneu- rism of the aorta, has varied, according to the experience of the writer, from ten days to eleven years ; but it may be much longer. The situa- tion and relations of the aneurism ; its complica- tions ; the constitution of the sac, and the state of its contents; the previous health and present habits of the patient; and the advantages enjoyed in regard to rest and treatment — will all ma- terially influence the prognosis, Trhether as to duration of life or prospect of recovery. Death in aneurism of the aorta may result from — (a) rupture of the sac; (6) exhaustion from pain, loss of sleep, or leakage of blood ; (c) asphyxia; (d) syncope; (e) inanition; or (/) intercurrent disease. The foregoing represents the order of relative frequency of the several causes men- tioned. Eupture of the sac is not, of necessity, immediately fatal. Haemorrhage may be stayed, and life thus protracted for several days, by ob- struction from the extravasated blood, itself ar- rested and coagulated in the surrounding tissues, or by its pressure upon the aorta on tie proximal side of the sac. Eupture into one of the cham- bers of the heart, the pulmonary artery, either vena cava or the innominate vein, the portal vein, or the biliary passages, is usually fatal within a very brief period ; whilst rupture into one of the serous cavities in the absence of previous adhe- sion, into the trachea or bronchi, or into the ali- mentary or the spinal canal, is instantaneously fatal. Tbeatmknt. — The treatment of aneurism of the aorta is palliative and curative. Pain from nerve-pressure_ is most effectually relieved by hypodermic injections of morphia, one quarter to half a grain in solution, repeated and increased in quantity according to necessity. The pain and oppression due to congestion of the sac and the surrounding structures is best treated by local or general abstraction of blood, combined with the use of cardiac and vascular depressants, especially iodide of potassium (20 to 30 grains every fourth hour), chloral hydrate (20 grains), and veratrum viride or aconite (5 to 10 minims of the tincture every third hour). Mechanical support by means of a well-constructed shield is likewise AORTA, DISEASESs OF. useful ■when the tumour projects externally. Fixed pain in the back, due to erosion of the vertebrte, is most effectually relieved by a seton or issue in the vicinity of its seat. The curative treatment of aneurism of the aorta may be classi- fied under the heads of— (a) compression of the artery, proximal or distal; (6) distal ligature; (c) absolute rest with regulated diet; and {d) the use of medicinal agents promotive of coagu- lation within the sac. For the details of these several modes of treatment the reader is referred to the articles in this volume respectively entitled ANBtTEisM, Abuqminal Anbueism, and Thoeacio Anbueism. Thomas Haydek. AOBTIC VALVES, Diseases of. See Heaet, Valvular Kiseases of. APBPSIA (4, priv., and viirra, I digest).— Indigestion. See Diqkstios, Disorders of. APEBIEITTS {aperio, I open). — ^Medicines which produce a gentle action of the bowels. Sea PDBGATrvES. APHAOIA (4, priv., and ipdya, I eat). — In- ability to swallow. See DuQiuTrrioN, Disorders -.f. APHASIA (o, priv., and ^^l OT^ia, I speak). — Stnon. : Aphemia, Alalia; Fr. Apkasie. Desceiptiom. — Aphasia is the name given to a defect of speech from cerebral disease, to which much attention has been paid during the last few years. When it exists the patient is found to be unable to utter any proposition, though his occasional distinct pronunciation of some one or two words shows that his speechless condition is not due to a mere diificulty in the more mecha- nical act of articulation. Moreover, the patient's intelligent manner and gestures may plainly show that he understands what is said, and is capable of thinking, even though he is quite unable to give expression to his thoughts. This kind of powerlessness as regards speech is most frequently encountered in persons suffering from right hemiplegia, though it is occasionally met with in those who are paralysed on the left side, and at other times in persons who are not hemi- plegic at all. The aphasic condition is not always, as it ought to be, clearly distinguished from another ■which may be encountered in association ■with hemiplegia on either side of the body, atid to which the name Amnesia is given. The essence of this latter defect lies in the fact that the patient very frequently substitutes wrong words or names in the placd of those he wishes to em- ploy, as when speaking of his ' hat,' he calls it a ' brush ; ' or ■when seeking a ' pen,' he Jisks for a 'knife.' In a bad case of this kind the patient may be quite unable to arrange ■Words into a sentence capable of conveying a definite meaning, so that his speech is rendered unintelligible. Where this species of defect exists there seems to be an inco-ordinate action of those higher cere- bral centres whose function it is to translate thought into the corresponding motor acts of speech, so that ■wc get hesitation and delay in the utterance of right ■words, or, what is worse, the substitution occasionally of entirely wrong words or even of a meaningless set of sounds. APHASIA. 69 These amnesic or inco-ordinate defects were not at first recognised as being distinct in nature from those of an aphasic type, in which there is rather a loss than a misdirection of power in some of the higher centres, whence the incita- tion to the motor acts of speech proceed. The two kinds of defects, indeed, not unfrequently coexist to some extent in the same indivi- dual. When occurring in association with hemi- plegia, aphasia varies much in intensity accord- ing to the degree of general mental impairment with which it may be combined. During the first Week or ten days after the onset of such an attack the special defect may be scarcely recog- nisable, owing to the masking influence of the general mental impairment. The patient lies, perhaps, in a restless but otherwise lethargic state, taking no notice of what is occurring around him, and not allowing his attention to be fixed even for a moment ; so that there is at such a time no positive ground for concluding that he or she ■will subsequently manifest aphasic symptoms. But where recovery of general mental power begins to show itself, and the patient taking notice of what is passing around him, also attempts to reply to simple questions, the first signs of an aphasic condition may reveal themselves. He perhaps says 'yes' or ' no ' to all questions indifferently ; or if both words are used, it is inappropriately. Even in this stage, however, there may be defective power in the initiation rather than in the execution of many much simpler acts than those of speech. Attention to the nature of this defective power clearly shows that it is not occasioned ,by paralysis in the ordinary sense of the term. Thus a patient in this condition may not be able to protrude his tongue wh^n simply told to do so, though it may come out ■with much readi- ness when a sweetmeat is applied to the lips, or even when he is shown rathei: than told what we want him to do. After a time, however, such a patient may regain a considerable amount of general mental power, though he may be left more or less hemi- plegic, and may also present the aphasic defect to a marked degree. He readily comprehends everything that is said to him, and can ofteii understand what he reads. But at other times, as was the ease with one of Trousseau's patients, though able fully to understand when read to, he does not seem to understand when he himself attempts to read. He can, perhaps, play draughts or chess well, and by me.ins of gestures and pantomime can make his wants and most of his wishes fairly well understood by those accus- tomed to interpret them. Yet he may only be able to articulate some one or two words, or else combinations of mere unmeaning sounds, such as ' poi, boi, bah,' ' sapon, sapon,' or some other sounds which, doing duty on all occasions, constitute his only form of speech. On rare occasions, under the infliierice of strong emo- tion, the patient may blurt put some simple expletive or short phrase, such as 'oh dearl' Sometimes he can repeat a word which he has just heard uttered, though at other times he has no such power, and may even be unable to repeat, when told to do so, one of the stock words oT 70 APHASIA. Bonndi; to ■wliich he is accustomed to give utter- ance. In a few cases the patient has seemed unable to understand ■what is said, as though from some difficulty in realising the meaning of ■words. Words may have to be uttered very glo^wly and repeated several times to such a patient, and even then they may fail to convey their meaning. Yet the language of gesture, appealing as it does to the sense of sight, may be at once understood. The patient's po"wer of ■writing is necessarily interfered ■with ■when aphasia, as is so often the case, co-exists with right hemiplegia. Many BUoh patients, however, learn to write with the left hand to a variable extent, though others continue powerless in this respect. The varia- tions as regards the power of ■writing are, in fact, almost as marked as the variations in power of speaking, though these two classes of defects by no means run parallel with one another in the same individual. The writer has kno^wn a man who was quite unable to express himself in spoken words, ■write a fairly good letter with very few mistakes ; on the other hand, the per- formance of such a patient, without a copy before him, may be limited to ■writing his own name. At other times the patient is able to ■write only mere senseless combinations of letters ; or writing some words correctly, he makes mis- takes and substitutions ■with others— in fact, shows an amnesic defect in writing, and writes much as an amnesic patient speaks. Still more rarely it is found that an aphasic patient is, though not from want of manual power, unable to write even a single letter — in attempting to do so he makes mere unmeaning strokes. Looking to the mode in which these symptoms most frequently group themselves, we find in one set of cases defects of an aphasic type only, as follows: — 1. Loss of power, both of speaking and of ■writing {Typical JpAasia). 2. Loss of power of speaking, but power of ■writing pre- served {Aphemia). S. Loss of power of -writing, but power of speaking preserved (Agraphia). At other times aphasic and amnesic defects are combined in the same individual, and then we may have — 4. Loss of power of speaking, -with an amnesic defect in writing. 5. Loss of power of writing, with an amnesic defect in speaking, Or, lastly, mere amnesic defects alone may exist in speech, in writing, or in both modes of expres- sion. Pathology. — The recent concentration of attention . upon these defects of , speech was started by the enunciation of Broca's views as to the dependence of the aphasic defects upon lesions in or about the third left frontal con- volution. Subsequent investigations have in the main tended to confirm Broca's view as to the effects of injury to this convolution, though Meynert and others think that a lesion of the convolutions of the island of Eeil on the same side is more frequently productivB jof aphasic symptoms. But all pathologists are now agreed as to the fact that lesions in or about the third left frontal convolution are much more prone to give rise to aphasic symptoms than are corre- sponding lesions on the right side of the brain. It is commonly believed, however, that amnesia may be induced by superficial lesions on either side of the brain, and by le»Jons a,lso which vary much in their topograpnieal distribution. Aphasia occasionallyBuperveqes,independently of paralysis or convulsions, in individuals who have been subjected to great excitement or pro- longed overwork, when it may be due, perhaps, to mere functional derangements. In other cases it presents itself as a temporary condition, lasting only for a few hours or a few days, in a patient who has just had an attack of right- sided unilateral convulsions ; or, lastly, as has already been indicated, it occurs in conjunc- tion with a right-sided hemiplegia , produced either by brain-softening or by cerebral haemor- rhage. Cases belonging to the latter category vary very much amongst themselves as regards the degree of co-existing hemiplegia. If the third left convolution alone is damaged, by softening, the hemiplegic condition may be transient and incomplete — never, perhaps, affect- ing the leg appreciably. This condition is often induced by a small haemorrhage, or by a patch of softening produced by an embolism of that branch of the middle cerebral, artery which supplies the third frontal convolution ; but where the haemorrhage is larger, or where the main trunk of the middle cerebral artery is obliterated, either by an embolon or a thrombus, the aphasia is combined with much graver and more persistent paralytic symp- toms. In some cases in which typical aphasia is met with, no actual lesion of the third frontal convolution is discovered after death. This is due to the fact that these symptoms may be occasioned by a lesion which, whilst not im- plicating the third frontal convolution itself, severs or interferes with the efferent fibres pro- ceeding from this convolution to the corpus striatum, the next lowest nerve-centre ; so , that a lesion either of, the part of the corpus striatum in relation with the third frontal con- volution, or of the white matter intervening between the two, should be, and is found to be, as capable of producing aphasja. as a lesion of the convolution itself. The third left frontal convolution is not now supposed, as Broca put it, to be the seat of any ' faculty of language,' though the anatomical in- vestigations of Meynert and of Broadbent have shown that its relations •with other convolutions are exceptionally complex. Whether or not certain assumed higher centres J'or speech are situated in this part of the brain, it must at least be conceded that this convolution is in- timately concerned with the physical expres- sion given to thought in articulate speech and in written, language; it contains, in facti the sites (or nerve-centres) from whjch the volitional incitations to these muscular acts usually pass downwards to lower centres. We know that. the left hemisphere is the one from which the volitional incitations proceed in the case of ■written language, and it is pre- sumed that ths same half of the brain also takes the lead in the production of articulate speech. It is, therefore, a point of much interest when we find that, in , some of the exceptional cases in which aphasia has occurred in association vrith lesions on the right side of the brain and left APHASIA. hemiplegia, the individuals had been left- handed during life. Some of the, other excep- tional oaees, however, have not admitted of this ! interpretation, so that further observations are required. Tbeatment. — Where aphasia occurs after ex- citement or overwork, Tvithout paralysisi it is a ■warnipg of much importance, since it may be the precursor of much graver symptoms. Under such circumstances the patient requiires an abso- lute cessation from ■work for a time, and most careful watching. Stimulants may need to be di- minished, and bromide of potassium, with snmbul and other sedative remedies, should be adminis- tered. Where aphasia is a temporary condition in association with right-sided convulsions, or where it is lasting and co-exists with right-sided paralysis, the treatment of the aphasic condition becomes merged in that of the associated convul- sive tendency or paralytic condition, since, as a rule, an amelioration takes place in the patient's power of speaking coincidently with his improve- ment in other irespects. This, however, is not always th^ case where aphasia has co-existed with a partial hemiplegic condition ; the paralysis may be recovered from, whilst the aphasic defect remains more or less as it was. 'Where this is the case, an attempt should be made to teach the patient to speak again. Such efforts have occasionally been crowned with success (see Trans, of Clin. Soc, vol. iii. p. 92), but much judgment ahd untiring patience have to bo called into play in order to obtain satisfactory results. H. Chaelton Bastiajt. APESMIA (ct, priv., and <^lit, I speak). &e Aphasia. ^^ APHOK"IA (o, priv., and ^avri, the voice). — Absence of voice, that is, of intonated utterance. Sis* Voice, Disorders of. APHKODISIACS ('A.()poS£Tj;, Venus).— DEFDnrioN. — Medicines which increase the sex- ual appetite and power. • Endmehation. — The direct aphrodisiacs in- clude— Nux Vomica and Strychnia, Phosphorus, Gantharides; Urtication and Flagellation ; Can- nabis Indiea, Opium, and Alcohol in small doses. Iron and bitter tonics ; meat diet; warm clothing, especially around the hips and loins ; and absti- nence from severe mental and bodily work act as indirect aphrodisiacs. Action. — Aphrodisiacs may act by increasing the excitability of the nerves passing to or from the genital organs. Or of the genital centre in the spinal oord (see Anaphkodisiacs), as, for ex- ample, strychnia, nux vomica, and probably phosphorus; by causing irritation of the nerves of the genital or urinary organs or of adjoining parts, as cantharides and urtication ; or by sti- mulating the brain, as Indian beniip or small doses of Opiuin. Alcohol in large doses has a double action, increasing the sexual desire by sti- mulating the brain, while lessening the power of erection, probably by weakening the nerves through which the spinal centre acts on the genital organs, or depressing this centre itself. As the sexual passion 'becomes diminished when the nervous system is weakened with the rest of the body, and increases with returning strength, aphth.;e. 71 iron with bitter tonics,^ and generou- diat act in- directly as aphrodisiacs. Uses, — When the sexual functions are abnor- mally depressed, strychnia and phosphorus are the most generally useful of the direct aph- rodisiacs. Cantharides, although sometimes valuable, must be employed with caution. T. IikVDsa Bbvnion. APHTHA— aphthous TTLCBBS (fiir™, to inflame). — Stnon. : Fr. Muguet ; Qer. Faach. Sescbiftion. — In some states of debility and deranged digestion the tongue, together with tho other parts of the mouth, becomes studded vrith small flakes, like morsels of cui-d, which are known as aphthtB. Sometimes these flakes extend and coalesce, so as to form large patches of thick, soft fur. This condition is particularly apt to manifest itself at the extremes of life — in infancy and old age — but it also occurs in the later stages of wasting or idebilitating complaints. The. white flakes can easily be detached, but, if this is done, they are soon reproduced. It is better, therefore, not to detach them, but to aim at removing the conditions which are essential to their existence, if they are forcibly detached, they are apt to carry the epithelium along with them, and to leave the ;papillse raw ; and these raw spots are prone to ulcerate. Aphthous ulcers have a very character- istic appearance. They are small, flat, and cir- cular or oval; generally occurring in clusters, and, as it were, in successive crops. Their bases are soft and smooth, with a thin yellowish or greyish slough; their margins are well-deflned and surrounded by a bright red areola, without thickening or elevation. They are commonly situated on the fore part of the tongue and the lips, where they are always accompanied by in- creased heat, and vivid congestion of the mucous membrane. At the same time there is generally Fig. 1.— Wdimn albicans. active gastric'or intestinal irritation, as well na fever of an atonic kind. It was not till 1842 that the precise nature of these white patches was ascertained. In that 73 APHTHJE. year it was shown by Gruby that they depend apon the presence of a microscopic fungusj to which he gave the name of aphthaphyte, or eryp- togame du muguet. Subsequently this fungus was referred by Jiobin to the genus oidium, and by him called oidium albicans. It is found growing upon the tongue in close association with the epithelium. It forms delicate, horizontal filaments, which are apparently homogeneous in structure, and from which short articulated pedicels take their pise. The uppermost cells of these pedicels become expanded into oval bodies which fall off, germinate, and become new fila- ments. It is generally found growing in tangled masses, like minute bunches of mistletoe, mixed with the debris of scattered spores, cells of the leptothrix, and epithelial scales; but if separate filaments are followed out we may obtain such forms as those represented in Fig. 1. Many ulcers are called aphthous which are really dyspeptic, and which owe their origin to stomatitis and irritation of the intestinal canal. The true aphthous ulcer, however, is always accompanied by the growth of the parasitic fungus that has been described above, and to such ulcers the term ought to be confined. The treatment of this affection will be found described under Thkush, a popular term which includes both aphthae and the dyspeptic ulcers resembling them. Some writers speak of aphthous ulceration of the vagina, by which is meant a severe form of vaginitis attended by the formation of small ulcers resembling the aphthous ulcers. The oidium albicans is frequently met with in the vaginal secretion. W. J?aielie Clarke. APHTHOUS. — A term applied to diseases in which aphthse are present. APLASTIC (4, priv., and irKiaaa, I mould). — Incapable of being organized or of forming tissues ; generally applied to inflammatory exu- dation. APNETTMATOSIS (fc, priv., and ■/rviviia, respiration). — A synonym for Atelectasis. See Atelectasis. APWCBA (o, priv. and irw'oi, I breathe), lite- rally signifying breathlessness; is used by some medical writers as synonymous with asphyxia (see Asphyxia), the condition which supervenes on suspension or obstruction of the respiratory function. By physiologists, and with more justice, the term is employed to signify the cessation of respiratory movements which is brought about by hyperoxygenation of the blood, as when an animal is made to breathe oxygen, or to breathe more rapidly than the needs of the economy re- quire. APOLLIH'AB.IS, AVaters of. — Acidulous alkaline table-waters. See Mineral Waters. APOPLEXT. — Definition. — The word apoplexy meanS( by its etymology, a striking from {knh, from, and irXJjJis, a striking), and was at first and is still chiefly used to signify sudden abolition of consciousness and power of motion, which, in common English, is also called a stroke. Cere- bral haemorrhage being the most frequent cause APOPLEXY, CEEEBEAL. of this condition, 'haemorrhage into the brain' and ' apoplexy ' came to be used as synonymous expressions. Subsequently the cflSision of blood itself was spoken of as the apoplexy, the word being used to designate the pathological condition causing the symptoms which it at fir^t epitomised. Ultimately it was applied, to a similar patho- logical state elsewhere, and thus haemorrhages into the substance of the lung, the spleen, or the retina were, and still are termed respectively pulmonary, splenic, or retinal ' apoplexies.' The term cerebral apoplexy is sometimes used to particularise haemorrhage into the brain, but it is more commonly employed to denote an apoplectic condition depending on any cerebral lesion, and in that sense it will be here employed. "W. E. GOWERS. APOPLEXT, ClEEEBEAL. — Stnon. : A Stroke; Fr. Apopleicie; Ger. Sohldg. Definition. — Ibss of consciousness, of sen- sation, and of voluntary motion, coming on more or less suddenly, and due to a morbid state of the brain. This condition of coma is termed ' apoplectic when of sudden or rapid onset. Loss of con- sciousness may be due to other causes acting directly on the braiu, such as defective or exces- sive supply or altered condition of blood; but it is customary to include among the forms of apoplexy only that sudden loss of consciousness which is due to cerebral congestion, and to con- sider as apoplectic states only those which result from distinct toxaemia. JEtioloot. — The apoplectic condition may be due (1) to the influence upon the brain of a poison circulating in the blood; (2) to a sudden cerebral lesion, such as haemorrhage or vascular obstruction; or (3) to a sudden shock or other impression arresting the cerebral functions, but causing no visible alteration in the brain. 1. The toxsemic states in which apoplectic symptoms occur are those of uraemia, drunken- ness, and poisoning by narcotics, as opium, &c. These are described elsewhere, and need be referred to in this article only in respect to the diagnosis. 2. The great cause of apoplexy is a sudden cere- bral lesion, which may be traumatic or may occur without external injury. Injury may lead to apoplexy by simple concussion, by laceration of brain, or by rupture of vessels and haemorrhage. Apoplexy, not due to injury, may be caused by congestion ; by thrombosis or embolism ; but especially by haemorrhage. The latter is its most common and most efficient cause. Profound ccma is rarely due to any other spontaneous cerebral lesion. A very small haemorrhage may cause apoplexy, 3. Lastly, apoplectic symptoms may occur with- out obvious lesion of the brain. The coma which results from concussion, that which succeeds an epileptic fit, and that which, in the absence of any recognisable cause, has been called ' simple apoplexy,' furnish examples. Patholoby. — In all these cases the apoplexy is in relation chiefly to the extent and suddenness of the lesion. Eoughly speaking, its occurrence may be said to depend on the suddenness, its degree on the extent of the cerebral mischiet Butthe occurrenceof apoplexy depends sometimea APOPLEXY, CEEEBKAL. ts on the size of the lesion, and the degree varies not only directly with the extent of the mischief, but with the extentof brain-tissue which is exposedin- direetlyto tie irritative influence of the primary lesion. Hence position of lesion has an important influence in determiningthe apoplectic symptoms. For these several reasons apoplexy is especially Erofound when the haemorrhage affects both emispheres, either by simultaneous extrava- sation on each side, or as the result of heemor- phage into the lateral ventricles. The precise condition on which the apoplexy is immediately dependent has been a matter of dispute. It was formerly ascribed to the pres- sure exerted by the clot on the rest of the brain, , either influencing directly the cerebral tissue, or pressing on and emptying its capillaries (Niemey- er). That such pressure is exerted by a large haemorrhage is unquestionable. The convolu- tions on the side of tlie extravasation are flat- tened, and the falx is bulged to the opposite side (Hutchinson, Jackson). It cannot be doubted that the intensity of the apoplexy in these cases is due in part to this cause. But tliis will not explain tlie occurrence of the symptom in small hamiorrhages, by which no general pressure is ex- erted, or not more than is at once relieved by the displacement of the mobile fluid vrhich sur- rounds the vessels. It will not explain its occur- rence in laceration of the brain, or the early loss of consciousness in severe haemorrhage, in which, as Jaccoud insists, it should, if merely due to pressure, be a late rather than an early symptom. There can be little doubt from these considerii>- tions, and from the cases in which there is no recognisable brain-lesion, that shock is an im- portant element in the causation of apoplexy. Thus in cerebral haemorrhage the apoplectic' symptoms are due in part to the influence on the rest of the brain of the irritation of the nerve- elements by laceration. We can thus understand why vascular occlusion causes a slighter degree of apoplexy, since the immediate irritation of the local anaemia is less than that of laceration ; and also why lesions of the'pons produce as they do such deep and long-continued coma, since the irritated fibres are connected with, and thus influence indirectly a large part of the cerebrum. Simple Apoplem/ was a term given by Aber- crombie to the cases, once thought to be frequent, in which apoplexy occurs without recognisable brain-mischief or blood-poisoning. Some of these cases were probably instances of uraemic poisoning, and others may have been due, as Dr. Bastiau suggests, to capillary embolism. But cases are not infrequent to which neither of these explanations applies, in which death occurs in an apoplectiform attack, all organs being found healthy, and the brain only eidiibiting, in common witli the other organs, that passive con- gestion which results from an asphyxial mode of death. The nature of these cases is still mysterious, but they may be grouped with those in which fatal coma follows an epileptic attack, and is apparently due to the brain-shock pro- duced. Serous Apdplem/ is a term applied sometimes to cases of fatal apoplexy in which no lesion is discoverable except excess of serum on the fi'irface of the biaio. It is now understood that such serous effusion is met with constantly in atrophy of the convolutions, rarely in Bright's disease, and under no other circumstances. There is no reason for associating its presence with the apoplectic symptoms. The cases de- scribed under this term were probably instances of uraemia, or of ' simple apoplexy ' in old persons with atrophied brains. Symptoms. —The prominent feature of apoplexy is loss of consciousness without obvious failure of the heart's action. The onset is often instanta- neous, so that the sufferer falls to the ground. The face may be flushed or pale — it is rarely very pale. The heart and arteries beat, often with undue force and lessened frequency. Ee- spiration continues, but is laboured ^ndstertOTous, with flapping cheeks. The limbs are motionless. In severe cases no reflex action can at first be excited. The pupils may bo dilated, contracted, or unchanged ; in profound coma they are usually dilated ; and they often vary in size spontaneously, being sluggish in their action to light. The patient can usually swallow, although often with difSculty. The sphincters permit the escape of urine and faeces, or the urine may be retained. In a case of moderate severity the reflex action soon returns, the conjunctivae become sensitive, and the patient can be roused to exhibit some sign of consciousness, shows returning power of voluntary motion, opens his eyes when spoken to, and tries, when told to do so, to pro- trude his tongue. On the other hand, the apo- plexy may continue or may deepen in intensity, the patient dying at the end of a few hours or a few days. Death rarely occurs in a shorter time than two or three hours. In very rare instances an extensive haemorrhage into the pons or medulla m^iy stop the respiration and kill the patient in a few minutes. It is not often, however, that there is this simple loss of cerebral function, uniformly dis- tributed, and gradually deepening or passing away. Much more commonly the symptoms of a local cerebral lesion are added to those of apo- plexy. Frequently such symptoms precede the loss of consciousness — unilateral weakness, deviation of the niouth, convulsion. They may be recog- nised during the attack : the limbs on one side exhibit more complete muscular relaxation than those on the other ; they full more helplessly when raised ; or there is unilateral rigidity or clonic spasm, unvaried in its seat; or inequality of pupils is observed, or rotation of the head and conjugate deviation of the eyes. As the patient recovers, these local symptoms become more and more distinct, the tongue deviates on protrusion, speech and swallowing are difficult, or the patient may have lost the use of language. In ingravescent apoplexy the commencement of the cerebral mischief is marked by symptoms of general shock, without any, or with merely transient, loss of consciousness. There is com- monly pain in the head, and there may be other localising symptoms. After some hours, during which the patient may continue his occupation, coma gradually comes on and deepens into death. This form of apoplexy, first described by Aber- crombie, is usually due to a slowly increasing cerebral haemorrhage. . The temperature in cerebral apoplexy is at flret 74 APOPLEXY, CEEKBEAL. always lo^reredj but usually the fall is small; and: is succeeded, after twelve ; to twenty-four hours, by a rise. - 1 - DiAONOSis; — From tbe unconsciousness due to cardiac syncope, apoplexy is easily distinguielied. In the former the heart's action foils, the pulse is weak and imperceptible, the' face is very pale, the respiration is sighing and irregular, reflex action is rarely abolished, and.the sphincters are seldom relaxed. From theseveral forms of ^oxismut thediagnosis is often easy, sometimes extremely dif^cult. It is easy when, on the one hand, the symptoms of apoplexy are preceded or accompanied by those of a local cerebral lesion; or when, on the other hand, the direct or circumstantial evidence of poisoning is dear, or the symptoms of toxaemia unmistakable: Where there are no local symp- toms, and where no guiding, ihistory is to be obtained,-the diagnosis is difficult, but.a correct opinion may commonly be formed by an attentive comparisoa of the symptoms present. Thei:e may. be,, as juBt:observed, indirect evi- dence of toxEemia: thb breath may smell of opiuni or alcohol; the urine may contain albu- min. But albuminuria or a smelLof spirits may mislead. Cerebral hsemorrhage often occurs after drinking ; spirit is constantly given to a person in a fit. A smell of spirit must therefore only be allowed weight in the absence of any .evidence of cerebral mischief. So, too, albumin is always present in the urine in uraemia, but it is also very frequently present , in cases of cerebral hsemor- rhage. Alone, this evidence of , Bright's disease is of little value, except there be general oedema and the patient be young; then uraemia is more probable than vascular degeneration and cerebral haemorrhage. But with other symptoms whichi indicate uraemic poisoning, albuminuria is con- clusive, i The age of the patient ' shouldi be considered. Late life is in favour of brain-disease. The history of a fall or blow on the head adds weight to other symptoms of cerebral mischief. i The character of the. coma will sometimes guide. In uraemia, andcommonlyin alcoholism, it is less profound than in cerebral mischief. The patient can readily be^ roused. > In apoplexy, in opium-poisoning, and in the most intense alcoholic- poisoning, the coma may be profound. On the other hand, in cerebral haemorrhage the patient, as Dr^Hughlings Jackson remarks, may sometimes be rousedito answer questions. Violent struggling is strongly in favour of drink. The modeof onset of the coma is important. In apoplexy it is sudden ; in uraemia slow. The uraemic patient becomes first, drowsy, then coma- tose. But with convulsions! ursemic coma may come on suddenly. The onset of the coma of, opium- and alcohol-poisoning is also slow. In- gravescent apoplexy is' of' deliberate . onset, but a profound degree of coma is, quickly reached. General convulsions at the onset exclude drunk- enness, and usually opium-poisoning,; while they : favour uraemia. Cerebral miachiefi sometimes ; commences with a convulsion, but the convulsion ■ is then commonly, unilateral, and ona-gided . symptoms are almost always: afterwards to be recognised. Bigidity of limbs or liocali muscular twitching during the coma is, if constant in s6at. in favour, of cerebral mischief ; if rariable iF position, it is in, favour of uraemia (Eeynol^e) -Post-epileptic coma is of course preceded by a convulsion, and should be borne in mind. The state of the pupils is alone of , little im portance. Great contraction occurs in and suggests opium-poisoning, but it is present in haemorrhage into the pons Varolii. The pupils may be normal or dilated in uraemia, in alcoholic or. opium-poisoning, and in apoplexy. Inequality of pupils, an unilateral symptom, points to brain-mischief. The retina should be examined, since the presence of albuminuric retinitis points, in the absence of, the signs of ajlocalised cerebral lesion, strongly to uraemia. Lastly, the temperature should be noted. I^ uraemia there is persistent uniform depression ; in cerebral, lesions the initial depression! is suc- ceeded by a rise, to a point above the normal. The diagnosis of the caiise of cerebral apoplexy will be described more fully under the heads of cerebral congestion, haemorrhage, and softening. It, may be iere pointed out that slight- and transient apoplexy, without local symptoms, with flushed face, and coming on ,during efiort, points to cerebral congestion ; slight and transient apo- plexy with markedlocal symptoms points to soften- ing ; early and profound loss of consciousness to cerebral haemorrhage, Post-epileptic coma may be distinguished by the history of epileptic attacks ; or, if this be not forthcoming, it may be suspected if symptoms of local cerebral lesion or indications of toxaemia are absent, if the patient be under 40, and exhibits indications of speedy recovery. I ',Simple apoplexy ' cannot be diagnosed during life, since freedom from the symptoms of a local lesion does not afford ground for inferring that there is no such lesion. Pkognosis. — The prognosis in cerebral apo- plexy depends in part upon the intensity of the attack. As long as unconsciousness is complete, and refiex action abolished, the patient is in danger of speedy death. The longer the apoplectic con- dition lasts without improvement, the less pro- spect is there of reooveigr. Persistent depression of temperature,.or a rise of several degrees above thei normal after an initial fall, are both of grave significance : such cases rarely recove* (Charcot, Bourneville). Th6 nature, extent, and position of the cere- bral ,lesion( when . they can be imfeired, furnish other prognostic indications. , In haemorrhage the prognosis is more serious than in softening. A sudden occurrence or increase of apoplectic symptoms, a few hours or days after a slighter attack, isi always grave, indicating a fresh ex- travasation. If such apoplecti e symptoms become profound and uniform, the prognosis is fatal, rupture into the ventricles or on the surface of the brain. haying probably occurred., If the localising symptoms point to a lesion of the .medulla oripons, the prognosis is almost as un- fajourable. Early return of. consciousness and slight alteration in temperature are favouioble signs. Previous cerebral disease renders the prognosis worse. Lastly, the prognosis must be influenced unfavourably by any inLpaixment ci the organic functions of circulation snd recpic-a- tion,iwhether-.independent of or due to thocixo- bral lesion. APOPLEXY, CEEEBEAL, 'f BEAXMKNT.-rTho treatment of cerebral afio- plexy must be guided iby the indications of its cause. Where none can be obtained, it should be treated , as. cerebral .. haemorrhage. ,' Still- ness is the most important condition. The patient should be moredas little as possible, but ^Itwed in the recumbent posture with, the head slightly raised. The neck should baftoed from constriction. If the estremitjes are cold, -warmth may beapplied to them; and cold to , the head if there is local heat or flushing. Sinapisms to the neck and ex- tremities sometimes seem to hasten the return of consciousness. The administration of stimulants should be regulated by the state of ths hearf. In thrombosis or embolism the heactshould be kept up to the normal by very pareful administration of alcohol, ether, or ammonia. In haemorrhage it may be allowed to fall a little below the nor- mal, but indications of failing power should be watched for aijd counteracted. Where no causal i indication exists, the latter is the wiser plan.: Venesection and purgation are remedies of similar effect, but different in degree, and aie indic;ated by high arterial tension and caphiio conges- tion, shown by ipcompressibility of the pulse and flushing of the face. Venesection is useful where the heart acts strongly, and the pulse is full as well as incompressible. Its effect is proportioned to the rapidity with which the blood is taken, rather than to the quantity removed. Purgatives remov* serum from. the blood, and lessen the amount of blood within the skull by causing an'afflux to the capacious intestinal vessels. The best purgative is croton oil. With a failing heart and pale.r surface they should be avoided. Diuretics may then be used to relieve the. vascular tension. As the apoplexy clears, the nature of the case becomes evident, and the treatment of the several conditions is described elsewhere, (See Brain, Hemorrhage and Soften- ing, of.) For treatment of the other causes of the npoplectic state, see Alcoholisu, Poisons, and UREMIA. W. E. GOWEHS. AFFEITDIX VEBMIFOBMIS, Inflam- mation, Ulceration, and Perforation of. PEE;iNi'rioK.T-Inflammatioii of the appendix vermiformis from lodgment of: hardened faeces or a foreign body, leading to ulceration, frec(uently ending in perforation of the coats ; to inflamma- tion, and suppuration of adjacent tissues (peri- typhlitis) ; and to peritonitis, local or general. iEiiOLOGY The usual cause of thisi affection is a foreign bpdy {e.g., fruit-pips or -stones, a small bone, shot, pins, &c.) ; or a faecal concretion imprisoned within the cavity of the vermiform appendix. Perforation has been recorded in ty- phoid fever and tuberculous disease. Anatomical CHARACTBBs.-^Before perfora- tion, takes place the appendix may be found distended with pus ; a foreign body or concretion lodged within it; and the mucous membrane ulcerated. The; conisretiuQ or concretions vary in size from a small pea to a bean ; are usually brown and hard ; and consist of layers of con- densed faeces, secretions, and phosphates, depo- sited around a small nucleus, which may prove to be a seed or other foreign body, or a piece of nnusurtlly inspissated faeces; These concretions greatly, resemble, and are often mistaken for. APPENDIX VERMIFOEMIS. 76 fruit-stones. Ulceration and perforation may oc- cur at any part of the appendix, usually, however, at the extremity or the lower third. There may be a circumseribed peritoneal abscess ; or the perforated part of the appendix may be found ad- herent to the surrounding parts, for example the caecum or the abdominal wall. Symptoms. — Pain, generally ill-defined, in the right iliac region, mayibe the only symptom to attract attention, and, as a rule, it is not until local peritonitis or perityphlitis is set up that we may suspect the nature of the disorder ; the ab- sence of premonitory symptoms, of the character- istic tumour of typhlitis, and of intestinal ob- struction, excsluding inflammation of thb caecum. Often, however, the course from the first is latent, and the mischief is suddenly revealed by perfor- ation into the peritoneum, followed by general and rapidly fatal peritonitis. Adhesions formed in front of the slowly advancing ulceration may localise the consecutive inflammation. The substance imprisoned within the appendix may be dislodged by (a) inflammation and sup- puration of the tissues around the caecum (peri- typhlitis, pericaecal abscess) ; or (b) the appendix, at the point of perforation; having become adhe- rent to the caecum, a communication is estab- lished with this part. SiAQNosis. — Inflammatory affections of the caecum and of the appendix can rarely be clearly distinguished from each other. Inflammation of the appendix is apt to persist, continuing to be acute aud severe ; while caecitis may be subdued by free relief of the bowels. Caecitis with ulce- ration is apt to follow intestinal inertia ; while the alarmingly acute and rapidly fatal 'symptoms of infiammaition with ulceration and perforation of the appendix often arise duri ng perfect health. Inflammation of the cellular tissue surrounding the caecum (perityphlitis) is more commonly tlie result of ulcerative inflammation of the caecum than of the appendix. ■ The complete investment of the appendix by peritoneum contributes to perforation and fatal general peritonitis. Pboonosis. — General peritonitis from sudden perforation into the cavity of the peritoneum is the great dinger, recovery from which is extremely rare. . Inasmuch as this may occur at any time during the course of ulcerative inflam- mation of the appendix, a guarded opinion should always be given when there is suspicion of the existence of this affection. Continued uneasiness in the right iliac region without indications of faecal accumulation, or of inflammation in or around the caecum, should not bei regardea lightly. Though this serious . accident is less apt to occur after the formation of adhesions around the advancing ulceration; we must not forget that well-marked local inflammation of theiperitoneum, or of the cellular i tissue around the caecum, does not always prevent it, inas- much as the adhesion which may thus form may not be sufSeiently strong, to withstand the pres- sure of pus in the appendix. - Tee ATMBNT.^-The patient must be kept at rest in bed, hot poultices applied,and an uiirritating fluid, diet allowed; Opiates, for the purpose of relieving pain and subduing the peristaltic con- traction ot'ithe- intestines, should be freely and continuously administered ; and if irritability' of 76 APPENDIX VEEMIFOEMIS. the stomaeh exist, they should be introduced by enema or by subcutaneous injection. Peritonitis or ether complications must be treated as they arise. G-eobgb Oliveb. APPETITE. — In disease the desire for food may be either leesened or increased ; or the appe- tite may be perverted, and a longing for various substances unfitted for or incapable of digestion may be displayed. Loss of appetite — Anorexia accompinies almost all forms of acute or chronic gastritis; and as these affections constantly coexist Trith other diseases, great variety as regards the desire for food is manifested in various complaints. In acute gastritis there is often not merely a loss of desire for, but «■ positive aversion to food, and the patient resolutely resists any attempt at obliging him to take either solid or liquid nourishment. In the more chronic forms of gas- tritis the distaste for food may be only slight ; in some cases the appetite is increased, but is quickly satisfied as soon as a small quantity of food is taken. In chronic ulcer of the stomach the appetite, as a rule, remains good, and the patient is only prevented from indulging it by the fear of the pain that will result from his so doing. Whenever the secreting structure of the organ is extensively diseased the appetite fails. Thus, in atrophy of the stomach the desire for food generally lessens along with the diminish- ing strength of the invalid. In cancer of the stomach there is always an extensive destruction of the glandular structure, and loss of the appe- tite is a constant and prominent symptom. It must be remembered that a loss of appe- tite may be more apparent than real. The phy- sician is constantly consulted on account of this symptom, when a little inquiry will show that the patient is really digesting as much as his syslem requires, but that by a habit of eating without allowing a proper interval between his meals, or by indulging in food of too nutritions a nature, or in an undue amount of aloohoUb stimulants, the sensation of hunger is prevented. Increase of appetite — Bulimia usually occurs where there is a necessity for an increased supply of food. Thus it is common after all febrile diseases, where the stomach has been long inac- tive. Again, in diabetes, where a large portion of the food is passed off in the form of sugar instead of being converted into the material required to keep up the nutrition of the body, there is an unusually large appetite. A craving sensation is a common symptom in chronic catar- rhal gastritis. It probably arises from the ir- ritation set up by the mucus and fermenting substances long retained in the stomach, and is temporarily relieved by eating. Tlie best treat- ment for such cases is to give alkalis about half an hoiir before the craving usually occurs, at the same time that the affection of the mucous mem- brane is combated by appropriate diet and reme- dies. In some persons the sensation of extreme hunger appears to arise from an irritable condi- tion of the stomach, by which the food is passed into the duodenum before digestion is completed. The sensation is mostly complained of at night, and the writer has found it a good plan to let the patient have some beef-tea or meat lozenges, AECUS SENILIS. for example, either just before retiring to rest or during the night. In children a craving for food is a frequent symptom, and arises either from the irritation of worms, or from chronic catarrh of the mucous membrane of the small intestines. Perversion of appetite — Pica is most common in pregnant or hysterical females. Curious articles, such as chalk, cinders, and' slate-pencil, are some- times swallowed. In the insane and in idiots articles Of an indigestible nature are not unfre- quently introduced into the stomach, such as stringi paper, cocoa-nut fibre, &c. It is a matter of great importance that all persons, but especially dyspeptics, should ac- custom themselves to control their appetite. Whenever a larger amount of food is taken than the stomach is capable of digesting, the residue is apt to ferment and thereby to produce gastric catarrh. This is more especially the case where the digestive powers have been enfeebled by previous attacks of gastric inflammation. S. Fenwick. APYEETICS. See Antipyretics. , APTEEXIA {It, prir., and irupeVcra, I aip feverish). — This word literally means absence of fever : it is also used to denote the interval between paroxysms of intermittent fever. . ABACENITIS. — Inflammation of the arachnoid membrane. See Meiongitis. ABOAOHOIT, "West coast of France.'— Summer and autumn resort. Sheltered by pine woods. Calm in winter. Bee Climate, Treat- ment of Disease by. ABCtTS SElTIIiIS is a croscentic opacity of the cornea, within its niargin, often seen in old people. Thearcus is usually first observed in the upper part, and soon afterwards a smaller opaqub crescent, opposite to this, appears below. In the course of years the two crescentie maris become tlightly wider and more opaque, their points having at the same time extended much more con- siderably in proportion, so that an annuhts or ring is farmed. It probably is always widest and most opaque above, and wider and more opaque below than at the sides. An arcus is grey when it first appears, but it may attain at last to an ivory whiteness. It is especially noteworthy that arcus, besides being regular in shape, of an evenly-graduated degree of opacity, and well-de- fined at its inner margin, is never continuous with the opaque sclerotic external to it, but is always separated from this membrane by an extremely narrow line of demarcation of unaffected corneal tissue, which, as it is normally almost transparent here at its margin, is the more conspicuous by force of contrast with the new opacity. At the same time it must be observed that the well-defined opacity is most opaque in the centre or slightly external to the centre of its width, at any part; so that, although it is everywhere well-defined, it is shaded off somewhat abruptly towards its outer circum- ference, and more gradually at its inner margin. The arcus is much more prone to increase in opa- city than in width. It rarely attains a width, even at the upper part of the cornea, of more than i in. It is very conspicuous when backed by a dark iris. The cornea within the regular boundaries of the arcus senilis remains perfectly transparent, and vision is in no degree impaired by it. Wounds ARCUS SENILIS. in tne part of the cornea thus affected heal well, and no surgeon is led by it to operate in any other part of ihe cornea, rather than divide the arcus itself in the part in which the corneal opening is made in almost all operations on the eye. Pathology and JEtiologt.— Arcus senilis is essentially a fatty degeneration of the proper substance of the cornea. It is not fully expiained why it should appear just where it does, so near to the source of nutrition of the cornea; the fatty substitute for the natural tissues seeming to occupy only the circumference, and first and chiefly under the upper and lower lid, where also the conjunctiva and sclerotic overlap the cornea more particularly — a situation in which the lids exercise a certain amount of pressure, which has been regarded by Dr. C. J. B. "Williams as the immediate cause of the degeneration. If an eye sufiers from chronic deep-seated disease an arcus will develop more rapidly ; as, for example, in a case of old recurrent iritis of one eye only, in which there was a well-marked arcus, while in the other there was hardly a trace of it. An anomalous case is that in which the upper and lower arcus are opposite as usual, but in an inclined meridian. Arcus senilis is as capricious in its appearance as other senile changes ; it is no clear indication of the age, certainly not of the number of years of life of a patient, as it may appear even in youth, and may never appear even in extreme old age,; hut when it occurs before forty years of age it is taken, by some life-insurance medical of^cers, to be an indication of concomitant fatty disease of tie heart and degeneration of the arteries. But fatty heart is often found without arcus, and ar- cus without fatty heart. If, together with other evidence of weakened heart-power, there be an arcus, it is probable that fatty degeneration of the heart exists. TiiBATKEKT. — Arcus Senilis is incurable, and no one endeavours expressly to check its increase, which, no doubt, is sometimes possible, as the writer is acquainted with a case in which the successful treatment of Bright's disease has, for ten years, completely arrested its advance. J. F, Stbkaimiij). ABDOB (ardor, heat). — ^A sensation of heat, burning, or scalding, which may be felt along the urethra during the passage of urine (Ardor Uriiue); or in connection with the stomach (Ardor Ventricnli), ABOTBIA (ipyvpos, silver).— The slate- coloured stain of the skin produced by the inter- nal use of the salts of silverj See Piomentaei Afeections. ABSENIO, Poisoning by .-Arsenic is classed as a metallic irritant poison, though its action is by no means limited to that of an ijrritant. It acts specifically on the gastro-intestinal mucous membrane, whatever be the channel by which the poison gains access to the system. The most usual source of acute arsenical poisoning is the administration of white arsenic or arsenious acid ; but the sulphides, various arsenides, and impure commercial articles, such as dyes, wall-papers, and pigments, may be fertile sources of arsenical poisoning. Poisoning by arsenic may be either acute or chronic. AESENIC, POISONING BY. 77 A. Acute Arsenical FolBoning, — This is the usual form of poisoning ensuing on the nefarious administration of any preparation of arsenic, but usually the oxide (arsenious acid) is employed. Symptoms. — The symptoms do not, as in the case of corrosive poisoning, come on immediately after the administration of the poison. There is most commonly an interval of half an hour or an hour between the swallowing of the agent and the onset of prominent symptoms. The quantity of the noxious agent, and its state as regards solubility, have also an obvious relation to the commencement of symptoms. Most commonly, after a sense of faintness and depression, intense burning pain is felt in the epigastric region, accompanied by tenderness on pressure. Nausea and vonuting quickly supervene, increased by every act of swallowing. Unlike what occurs in an ordinary bilious attack, with which arsenical poisoning may be at first confounded, the pain and sickness are not relieved by the act of vomiting. The vomited matters are extremely varied, and present no characteristic appearances. At first they usually consist of the ordinary con- tents of the stomach, but at a later stage are largely charged with bile which has regurgitated into the stomach in consequence of the violence of prolonged emesis; and they may be tinged witii blood. Ordinarily vomiting is speedily followed by violent purging, and great straining at stool, the motions being often streaked wil£ blood. Purging may, however, be entirely ab- sent. Other prominent symptoms are great thirst, a feeble irregular piUse, and cold clammy skin. The patient as a rule dies within eighteen to seventy-two hours in a state of collapse ; but tetanic convulsions are not uncommon, and even coma and paralysis may close the scene. Diagnosis. — From an ordinary bilious attack, induced by improper diet or by decomposing food, arsenical poisoning is diagnosed by the persist- ence of the symptoms after the removal of th& apparent cause ; and not infrequently by the symptoms remitting and again supervening on tie administration of food or drink of a parti- cular kind, or given by a particular hand. From choleraic diarrhoea it is distinguished by the sudden onset of symptoms, thirty to sixty minutes after food or drink has been taken ; by the absence of rice-water stools, or of lividity of the skin ; and by tie symptoms not yielding to treatment, , Moreover, in poisoning by arsenic there is usually greater tenderness over the epigastrium; the diarrhoea is less passive, and accompanied with more tenesmus than in choleraic diarrhcea ; the stools are more often bloody; and nervous symptoms may be more pronounced. The diag- nosis is, however, often very difficult, except wten aided by a chemical analysis of the matters ejected from the stomach or of the excreta, which should always be made in doubtful cases. Pbognosis. — This must always be uncertain, since it is rarely possible to ascertain the quan- tity taken, or to ensure its entire evacuation from the stomach. Treatment. — Emetics, diluents, and demul- cents are the appropriate remedies. The stomach- punip may also be usefully employed. In ad- ministering emetics, tartar emetic should be avoided, as it increases the depression, and its 78 AESENIC; POISONING BY. presence complicates a chemical analysis. More- over, tartar emetic frequently contains' traces of arsenic, and, in the event of an analysis being made, an unfounded suspicion may be raised. No confidence can be placed in thei so-called antidotes, y«ms hydrate wxSi magnesia, ejieeit where a soluticia of aisetie has been taken. B. Ohronio Axsenical Folaonins. — This form of poisoning is not uncommon, and is, unlike the acute form, generally : accidental. The inhalation of arsenical vapours in factories, or of arsenical dust, as from green and other wall-papers, and in the process of manufacturing artificial flowers, is a common source of chronic arsenical' poisoning. ■ Those who are chiefly exposed to this form of poisoning are persons employed in the manufac- ture of pigments, especially green pigments; paperhangers and decorators ; artificial-flower manufh.cturers ; milliners; persons exposed to the fumes of heated metals; particularly zinc and bi'ass ; manufacturers of dyes ; and leather- dressers; In the process of depilating sheep-skins, previous to the tanning or the tawing process; a toixturo of lime and orpimont (sa^Aiife of arsenic) is used ; and serious ulceration of the hands, scrotum, ndse, and cheeks not infrequently results. ' Persons living in rooms the walls of ' which are covered with arsenical paper, especi- ally bright-green papers containing arsenite of copper, are liable to suflTer from chronic arseni- cal poisoning. It is uncertain whether this is entirely caused by the mechanical transfer of pigmentary dust to the air-passages, or is piirtly due to volatilisation of the arsenic, probably in the form of arseniwetted hydrogen. Many Thrown wall-papers also contain arsenic, and arsenious acid is sometimes added to the size ; such papers have been known to produce the specific symp- toms of arsenical poisoning. i That some persons can take arsenious acid intcirnally with impunity in relatively large doses {araenie-eating) is now a well-established fact. Symptoms. — The first symptoms of chronic arsenical poisoning are usually loss of appetite, prsecotdial pains, irritability of the bowels, and occasionally headache. Suffusion of the eyes, a peculiar and characteristic appearance of the conjunctiva, often amounting to actual conjunctivitis, and intolerance of light are early manifested. The muscular power of the limbs is impaired pretty constantly, and Actual paralysis extending upwards from the lower extremities is occasionally observed, A cliaracteristic vesicular eruption on the skin {eczema arsenicale) is fre- quent, as well as irritation of the skin, especially over the neck, scalp, hands, and armpits. Males who handle arsenical preparaltions are liable to ulcerations of the scrotum and penis, obviously due Vo amechanical transference of the poison to the genitals when these are touched. If the source of the disease be not reraof ed, progressive emacia- tion, exfoliation of the cuticle, and nervous pros- tration supfervene ; and convulsions may precede the fatal termination. The effects of green' irsenical pigments are sometimes manifested by bleeding from the nose. DiAONosis. — When a patient suffers more or ' less from the symptoms above described, and is ilso known to be exposed to any of the sources I AETEEIES, DISEASES OF. of danger from arsenical poisoning enumerated under the aetiology, the diagnosis is not diflScult. Teeatmbnt. — The source of poisoning should invariably be removed. It is ibiind that those who suffer from working in arsenic make no progress towards recovery until they are removed from contact with the poison. Wall-papers which contain arsenic, and are suspected to be the cause of symptoms, shoiild be taken away., Quinine, or other tonics, iron, and, attention to the digestive organs will be needed. Bemoval to fresh country air is often productive of marked benefit. Soothing lotions to the skin, and careful attention to eroding ulcers, especially of the cheek, may be necessary. Shampooing and warm batlis form the best treatment for paralytic legions. MoitBiD ApPEAEANCES. — These are tha same by whatevei: channel the poison has gained access to the system. As a rule there is marked inflammation of the stomach and duodenum, 'usually of the small and large intestines also ; but not uncommonly the inflammation is limited to the stomach, duodenum, and rectum, the intervening alimentary tract having escaped. If, the poison has been administered in a solid form, white patches of the arsenical compound may be fouiidimbeddedinthickbloody mucus andinflam- matdry exudation. Portions of the white arsenic are also sometimes converted by the sulphuretted hydrogen evolved during decomposition into the yellow sulphide. _ Ulceration of the stomach ia rare; and perforation almost unknown. An ecchy- mosed condition of the heart is oft^ observed; and fatty degeneration of the liver, as in poison- ing by phosphorus, has been described. T. Stevenson. ARTERIES, Diseases of.— It is important to keep in mind the following anatomical facts in studying the morbid processes to which arteries are subject : — ^In immediate contact with the blood-stream in arteries lies the endothelium —a layer of flattened cells ; outside this is the tunica intima, composed of elastic tissue in (longitudinal arrangement : together the endothe- lium and tunica intima constitute the internal coat of the older writers. Still more external we find the middle coat, made up of muscular fibre arranged transversely, in the larger arteries mixed with elastic tissue ; and, most external of all, the external coat, consisting of longitudinally fibril- lated connective tissue. I. Acute Arteritis, aflfecting a very limited portion of a vessel, and leading to ulceration, occasionally occurs. In some cases this has arisen from the irritation caused by an embolus, which, becoming detached from a cardiac valve, has blocked a distant artery; and Dr. Moxon has specially drawn attention to its occurrence in the aorta, when the asoendingportion of the vessel has been exposed to theimpactofahard,fre6lymoving. vegetation on one of the segments of the aortic valve. Dr. Moxon has also described, under, the designation inflammatory moUities,the occur- rence of softening and swelling of the arterial tunics in circumscribed spoU; which become flabby and. inelastic, and ultimately bulge out- wards and form aneurisms. He believes that this condition depends on a peculiar general state, and is the great cause of aneurism in young, hard- ARTERIES, DISEASES OP. 78 vroi'Ung men. Except in these' circumsciibed inflammatoiy lesions, we do not meet with any condilioii of the arterial tunics td which the de- signation acate arteritis can be applied. Such a change has, indeed, been described, and the writer has seen the lining membrane of the ascending and transverse portions of the aorta of a bright vermilion hue, strongly suggestive of acute inflammatory change ; but the best 6b- serrers are now agreed in believing that this appearance Arises from staining by faeematin. 2. Chronio Arteritis has been described as puMuing a course different from the aidarterith deformans, which will immediately be noticed ; and as causing thickening of the coats of the vessels, narrowing of their calibre, and absence of pulisation during life. As such, chronic ar- teritis appears to be a disease of extreme ranty. But, on the other hand, if it' be Considered as the first stage of atheromatous disease, it may be said to be of frequent occurrence, 3, Feriarteritis is the term applied by Charcot and Bouchard to the ttorbid change which, in their opinion, eventuates in cerebral Lxmorrhage. According to these physicians, ■cerebral haemorrhage is not usually due to 'itheromatous decay of the vessels of the brain ; but, in the vast majority of eases, to the ttipture 3f miliary aneurisms, which in their turn have been produced by- a morbid process beginning in the perivascular sheath surrounding the cerebral vessels ; and which, proceeding from' without in- wards, ultimately involves all the coats of the vessels (see Bkaiit, Haemorrhage into). i. Atheromatous Disease, ttiB' Bhidarteritie deformans ai VirehoV, is the arterial disease which is most frequently met with, a-nd the one whose consequences are most serious; It presents three tolerably well-defined stages, (a) In the first stage we notice, when the vessel is slit open, greyish patches, by which the lining membrane is irregnlaTly thickened ; these patches seem to lie on the surface of the membrane, but this appearance is deceptive; the endothelium lies between them and theblood-strean\, and is, at least at the begin- ning of the morbid process, unaifected. The ma- terial of which the patches are formed is really situated between the tunica iutima and tunica media ; it is semi-cartilaginous in consistence, and is farmed by an abnormally rapid multiplication of the deeper cells of the tunica intima, — the new growth pushing up this tunic with its super-im- posed endothelium, and so causing a bulging into the interior of the vessel. The process is of the nature of an inflammatory change ; that is, it con- sists in the proliferation of cellular' elements', in consequence of some influence which has excited them to unnatural growth, (i) In the second stage the cellular elements of which the new gro'wth is composed undergo a process of fatiy degeneration; and in consequence it becomes yellowish in colour and pasty in consistence : it was the paste-like appearance of the mass in this stage which originally gained for the process the designation Atheroma (iS^fn) = m^al). It not nn- frequently happens that the whole of the internal coat "with its endothelium is involved in the softening, and gives way under the pressure of the 'blood, leaving an excavation, thd floor of which is formed by the nuddle and external coats of the artery, {p) In other instances, how- ever, the pasty mass, instead of being washed away, becomes the seat of calcific deposit. This is the third stage in the process. The appearance of a vessel in which atheromatous disease has reached this stage is very striking : plates which present to the naked eye the appearance, but' do not show the minutei structure of bone, are observed at intervals in the walls of the ves- sel, and their sharp spicula project into its interior ; in the aorta it is not uncommon to find such plates an inch long and half an inch broad, and in the smaller arteries the' calcific matter sometimes forms a ring round the vessel. In the latter the calcareous particles appear to be deposited in the patch while it is still firm, so that the second stage of the process is wanting. Atheromatous disease sometimes invades both the aorta and the small vessels, but the aorta may be extensively diseased and the small arteries unaffected ; or, on the other hand, the cerebral, temporal, and coronary arteries may be the seat of calcific change while the great vessels are healthy ;> occasionally the disease is limited tc afewvessels. Next to the aorta, the cerebral, coron- ary, and splenic vessels, and the arteries of the lower extremities, are prone to this form of arteritis. Effects; — The dangers to which an athero- matous state of vessels exposes the person in whom it exists are varied. The stream of blood is retarded by the projection of the new growth into the vessel, and still more by the destruction of the elasticity of its coats ; and hence ensues a failure in the nutrition of th6 organ which de- tpBndsfor its supply of blood on the diseased vessel : — this is said to be a cause of cerebral softening. When the paste-like mass is washed away it sometimes happens that the blood in- sinuates itself between the coats of the vessel, producing a dissecting anexirism ; or the portion of the vessel^ which lias been weakened by the removal of the internal coat, yields to the pressure of the current, and a sacculated aneurism is ori^nated; sometimes the diseased vessel bursts. Cerebral vessels, probably on account of the thinness of their walls, are specially liable to rupture ■when they are the seat of atheromatous change ; and occasionally a diseased coronary artery has given way, filling the pericardium with blood. Axteries have been completely occMed by the deposition of fibrin on the spiculated edges of calcareous plates: this is one of the causes of senile gangrene ; and embolic plugging of distant vessels at times results from the detachment of such fibrinous clots, and the washing away of atheromatous debris. Rigidity of the larger arteries' from atheromatous change is likewise one of the most frequent causes of hypertrophy of the left ventricle of the heart, on which increased work is imposed ill consequence c^f the destruction of the elasti- city of the vessels. Anasarca has not, so far as the -vpriter is aware, been - meintioned by any author among the consequences of diseased ar- teries ; but some cases which have come under his observation have led him to the conclusion that persistent anasarca, especially of the lower ex- tremities in elderly men, is- sometimes mainly due to a diseased condition of the arterial tunics. In the cases which he has observed there vmR 80 likewise present dilatation -with hypertrophy and commencing fatty change of the left ventri- cle, itself a consequence of the arterial disease ; but this seemed insufficient to account for the persistent oedema of the lower extremities. ^TIOLOQY. — The cause of endarteritis de- formans is now generally admitted to be over- strain of the vessel. It was formerly thought that syphilitic impregnation of the system was a power- ful favouring condition ; but Uiis Opinion rested chiefly on observations made among soldiers, who, in addition to the syphilitic taint, were subject to other influences now known to be adequate in themselves to develop the disease : and the writer has himself seen themost extensive atheromatous disease in men in whom there was no trace of the syphilitic taint. Intemperate habits and gout appear to be powerfully predisposing causes ; they probably render the blood impure, and its pas- sage through the capillary vessels being thereby retarded, the tension of the arterial system is increased. Besides violent exertion, which im- poses a strain on the entire arterial tree, there are other influences which act upon certain vessels. Thus the renal arteries are kept over-full in the cirrhotic form of Bright'a disease, owing to the destruction of the capillary tufts, and hence athe- roma of these vessels is almost constantly present in that form of renal mischief. The writer baa on two occasions found extensive calcareous formations in the cerebral vessels of persons in whom cerebral degeneration had followed ex- cessive anxiety and mental effort. The pul- monary artery is very rarely invaded by atheroma ; and only in cases in which it has been kept in a state of tension by hypertrophy of the right ventricle or disease of the mitral orifice. DiAQNOSis. — The diagnosis of atheromatous inflammation of the aorta will be discussed in a separate article. The existence of the disease in the arteries of particular organs can only be a matter of reasonable presumption when the patient is past middle life ; when the ascertained causes of atheroma have been in operation ; when symptoms of impaired nutrition of the organ are present ; and when the organ (the brain or heart) is one the arteries of which are known to be prone to the disease. Calcification of the super- ficial arteries renders these vessels rigid and tortuous ; the temporals when so affected attract the eye by their prominence, and may be felt hard and rigid beneath the finger j the brachial may equally be made the subject of examination ; and, although the presence or absence of athero- matous change in such superficial vessels does not necessarily prove that the other arteries of the body are in a similar condition, it renders it more than probable that they are. Those who are not familiar with the resisting feel of the radial artery, when it is the seat of the change now under consideration, are liable to form a very erroneous estimate of the strength of the pulse : this may convey to the inexperienced finger an impression of a force which it does not possess. The error also is sometimes committed of inferring the existence of aortic regurgitation in these cases in consequence of the tortuous course and visible pulsation of the superficial vessels ; bat they do not collapse suddenly under the finger, as do the vessels during the receding wave in AETEEIES, DISEASES OF. aortic patency. The sphygmographic tracing, moreover, is essentially different: in atheromatous disease of the artery the upstroke is vertical, and the summit of the tracing extended. _ The existence of such evidences of vascular mischief affords a fair subject for consideration to those who are called upon to form an opinion as to the eligibility of a life for assurance. Treatment. — The treatment of endarteritis deformans is mainly preventive. It consists in the avoidance of all those influences to which we have adverted as causes of the disease, namely, indulgence in alcohol ; causes originating a gouty state of the blood ; excessive muscular efforts, especially in constrained positions ; pos- tures which involve the long-continued con- traction of muscles which surround arteries ; and, as far as the brain and heart are concerned, all those states which favour overfulness of their respective arteries : — in the case of the brain, excessive mental application, deficient sleep, and, the writer believes, prolonged periods of sexual excitement ; in the case of the heart, inter alia, efforts which involve holding the breath, thus leading to distension of its right cavities, and imposing an obstacle to the return of blood from its walls. 6. Patty Degeneration, unconnected with the atheiromatous process, is sometimes, though rarely, found to affect arteries. Circumscribed opaque and velvety spots appear on the surface of the intima, and erosion ultimately occurs. Once this has taken place, the muscular coat, unable to bear the pressure of the blood-stream, fissures transversely ; and the blood either rup- tures the external coat, or, insinuating itself be- tween the middle and external coat, produces a dissecting aneurism. This change has been found in the arteries of persons who seemed otherwise quite healthy ; it is ' a morbid change which is simply degenerative from the first, and of whose immediate cause we know nothing' (Eindfleisch). Fatty degeneration of the external coat of the smallest arteries has also been no- ticed : it appears to be a senile change, and to play a part in the production of cardiac and cerebral degeneration. 6. Ca.lciflcation of the arterial tunics also occurs unconnected with endarteritis, but more rarely than fatty degeneration. When this is the case, it is the middle coat of the smaller vessels that is the seat of the deposit, which consists of carbonate and phosphate of lime and magnesia. The process is usually limited to the vessels in which muscular fibre is abundant; but these it may affect extensively, the super- ficial vessels and the arteries of the brain and of the extremities being the favourite seat : it is eminently a senile change. 7. Gummatous Disease of the cerebral arteries in syphilitic patients has been described by Dr. Hughlings Jackson, Dr. Wilks, and others. The vessels present nodose swellings, and are thick- ened sometimes to three times their normal size by gummatous material infiltrating the outer coat ; the calibre of the vessels is thereby nar- rowed, the formation of thrombi favoured, and cerebral softening produced. 'A random suc- cession of nervous symptoms,' to use the words of Dr. Jackson, affords strong grounds for sus- AETERIES, DISEASES OF. peoting syphilitic disease within the cranium ; and the writer has himself seen three cases in which such symptoms disappeared under the use of perchloride of mercury and iodide of potassium, and in whicli it seemed to him that the supposi- tion of arterial disease was much more probable than that of any other form of intracranial syphilis. 8. Albuminoid Disease, when it attach the spleen or kidneys, appears first in the walls of the small arteries of these organs, but is not found in the larger arteries, of the body. 9. Oontraction and final imperm^E^hility of an artery from atheromatous calcification, fro^n the accumulation of fibrine in its rough inner surface, from pressure, or from other causes, occasiQnally occurs, leading to gangrene of the extremity which it supplied. 10. Dilatation of arteries is in the ma- jority of cases due to previous disease of 'their coats ; but sometimes in the aged the arteries are found dilated without any degeneration of their tunics being present, — a stkte of aflTairs which Hindfleisch suggests may depend on atony of (he muscular coat, and in some cases ' may pos- sibly be connected with deficient innervation, 11. Aneurism receives full consideration in a separate article. Here it is merely necessary to point out the ways in which atheromatous inflammation and the other morbid processes which have been described contribute to the pro- duction of dilatation and aneurism. In some cases the course of events consists in the wash- ing away of the diseased patch of the intima ; when the middle coat either dilates, or, by separation of its muscular btmdles, undergoes rupture, and the external coat yields before the pressure of the bloqd-stream. In other eases the dilatation occurs, not at the point where the endarteritis has invaded the vessel, but nearer to the heart. At the affected point there is narrowing of the canal of the vessel, and loss of elasticity in its coats ; and as a consequence we have slowing of the circulation and deficiency in the supply of blood beyond, and increased ar- terial tension on the proximal side of the affected spot. The effect of this tension is more serious than would at first sight appear ; in health the blopd, propelled by each ventricular systole, enters contracted vessels, which, yielding before it, are uninjured by its sudden impact ; but a vessel in a state of tension is exposed to the full violence of the column of blood discharged by the heart, and must gradually dilate before it. 12. Arterial Disease in Insanity. — Accord- ing to Dr. J. Batty Tuke, and other physicians who- have specially investigated the morbid changes in the brains of the insane, arterial dis- ease is almost invariably present. It consists in such alterations as would result from obstruc- tion in the ultimate ramifications of the vessels ; — thickening of the proper coats of the arteries, and of the sheath of connective -tissue which surrounds the cerebral vessels ; the deposition of fine molecular matter and crystals of hsematoidin between the adventitia and the sheath ; and ex- treme tortuosity of the vessels. 13. Arterio-Oapiltety Fibrosis is the term applied by Sir William Gull and Dr. Sutton to the hypertrophy of the walls of the small arteries 6 ARTIFICIAL EESPIBATION. 81 found in the subjects of the cirrhotic form of Bright's disease. It is admitted by all observerH of repute that the walls of the blood-vessels of the kidney are greatly thickened in this malady ; but it is by no means so nniversally admitted that the small arteries througl)out the whole body are in aE such cases similarly hyportro- phied. That th^ are hypertrophied in a certain proportion of the cases admits of no doubt ; but the nature of the thickening remains to be do cided. Dr. George Johnson, who early called attention to this condition, considers that there is present an hypertrophy of all the tunics of the small arteries, especially of the muscular coat- a consequence of the obstruction which impure blood invariably meets within thecapillaries. Sir William Gull and, Dr. Sutton, on the other hand, assert that the thickening is due to a fibroid growth,, especially seated in the external coat of the vessel ; and they believe that the coexisting disease of the kidney is not the cause of the arterial -change, but that both are parts of a general diseased process. Jaues Litti.e. AETEKIES, Examination of. See Phy- siOAi. Examination ; and Pulse. ABTHEALGIA (i,fBpov, a joint ; and }i,\yat, pain). — Pain in a joint. The term is more par- ticularly applied to articular pain in the absence of objective disease. AKTHBITIS (fipflpoj/, a joint).— A term geuerically used to signify any disease whatever involving a joint, but more correctly confined to articular inflammation. It is also employed to designate inflammation of all the structmes forming a joint, as distinguished from mere syno- vitis. See Joints, Diseases of. ABTHBODTWIA (Spflpoi/, a joint; and oiivi], pain). — See Abthbalgia. ABTICULAB BHETTMATISM.— Eheu- matism affecting joints. See Eheumatism. ABTIFICIAL EESPIBATIOST, or the method of exciting and keeping up the move- ments of the chest, so as to supply air to the lungs, is a siibject of the highest importance, since the hopes of recovery depend on its due performance in many cases of narcotic poisoning, in the apparently drowned or asphyxiated, and in the collapse of the advanced stage of the condition induced by anaesthetics. For its effective employment it is essential.toseethatno foreign body obstructs the air-passages. Children and old people are liable to swallow large pieces of meat or crust, which become impacted in the pharynx or oesophagus. These should, if pos- sible, be dragged away with the finger or a spoon-handle, but they may require the use of a probang. Tracheotomy is rarely necessary. A knife-handle held between the molar teeth is a ready and useful gag to keep the mouth open. A button-hook, in the absence of pharyngeal forceps, is sometimes very serviceable. Vomited matter should be quickly removed with a sponge or cloth twistied round a piece of w.ood. In treating the half-drowned the body should be inverted for a few minutes to favour the escape of water from the air-passages, but artificial 32 ARTIFICIAL EEbPIRATION. breathing should be commenced even whilst the body is in this position. Methods.— In most eases the best method of commencing artificial respiration is to compress the chest and abdomen simultaneously, then remove pressure so as to allow air to enter the chest, and again repeat the pressure every two or three seconds. If the sound indicates that air is passing into and out of the lungs, this method may be continued for half a minute ; but if we are not sure that the air is exchanged, and in all oases if the patient's condition is not decidedly improved in half a minute, we should resort to : — • 1. Syloester's method. — Place the patient on his back on the floor, with a block or pillow under his shoulders, and raise the arms upwards above his head, by grasping them above the elbow, and pulling firmly and steadily as long as there is any sound of air enteringthechest. Some arrangement is needed to prevent the body from being dragged towards the operator. For this purpose the plan of raising the chest on a high cushion or box has been adopted, but as a condition of cardiac anaemia is often present, this is objectionable. It is better to effect the object by placing a book in front of the thighs while kneeling at the head of the patient. It may be needful to draw forth the tongue, but generally if the head falls back over a cushion placed behind the neck, this is not required. An artery forceps, or a noose of string, or a handkerchief will enable an assistant to keep the tongue well forward. As soon as the sound produced by the entrance of air into the chest ceases, the arms should be brought down a little towards the front of the chest, and pressed firmly and steadily against it for about one second after air is heard escaping. In cases of drowning it is enough to repeat this operation every four seconds, but in the collapse resulting from chloroform or other ausesthetics, the necessity for getting the vapour quickly out of the chest justifies a more rapid performance of the movements during the first five minutes. After this time the movements should be carried on more slowly, but they should be continued for half an hour at least, and even longer if the warmth of the surface and diminution of lividity gives any reason to hope that the heart has not entirely ceased to act. 2. Marshall Halts- ready method is performed by placing the body on one side, and alternately rolling it on its face to compress the chest, and on its back to allow the elasticity of the ribs free movement to draw air into the lungs. The plan is not nearly so effective as Sylvester's, but if no assistant is at hand it is the best mode of artificial breathing that can be adopted. 3. Howard's method. See Esstocitation. 4. Mouih-to-mouth insufflation is not to be depended upon, on account of the dificulty both of keeping the larynx open, and also of prevent- ing the air going down the gullet. Of the instruitients introduced for the purpose ot carrying on artificial respiration, mention should he made of those invented by Dr. Marcet and Dr. Eichardson ; but except in the hands of the inventors or of those who had gained much experience i n their use by practisi ng upon animals, the viriter thinks they would do as much harm U8 good. The objection to them all is that they ASCITES, interfere -with the prompt imitation of the move- ments of respiration just described. The administration of oxygen is indicated in most cases of artificial respiration, but the results of its use have not been satisfactory hitherto. Now that the gas can be had in a compressed state; and can be given by means of the la,ughing- gas inhaler, it is worthy of a further trial; bat it is certain that in all cases of impending asphjraiia time is of so much importance that anything which would delay the supply of oxygen would not be compensated for by giving it pure, in- stead of in the form of common air. IVacheo- tomy is not to be thought of in the first instance in any case in which air can be made to pass, even in very small quantity, through the trachea. For. supplemental and after-treatment, see Eesusoitation. J. T. Cloteb. ASCAHIDSS (affKiipls, a kind of worm). — This term, by long usage, is often employed to designate the very common intestinftl parasites popularly. iinownasThread-worms or Seat-worms. Strictly speaking, these do not belong to the genus Aecamis, but to the genus , Oxyuris. The faEer consideration, therefore, of their characters and clinical importance will be found under the Article Thekad-woems. Although the term as employed in the sense referred to is altogether erroneous, there are two true species of the genus Ascaris found infesting man. These are, respectively, the common round- worm or liUmbricus (Ascaris lambricoides) ; and the moustached or margined round- worm(.4scffins mystax). Full particulars respecting the former will bo found under Eound-woems, whilst the consideration of the latter need only, occupy a few words in this place. .Since the discovery and description of the Ascaris mystax as a genidne human parasite by the writer in 1868, six instances of its occurrence have been noticed at home and abroad, and there can be little doubt that the parasite is much more frequent in man, especially in children, than is commonly supposed, The writer has also shown that this parasite is identical with the Ascaris mystax in the cat, which, according to most helminthologists, is only a variety of the Ascaris marginata in the dog. The males are usually from 2 to 2^ inches in length ; the fe- males sometimes acquiring a length of 4 inches or more, Teeatmeht. — Like it? congener, the falsely so-called Lumbricus, the margined round-worm readily yields to treatment by santonine. Two or three grains of this drug, followed by castor oil, or a saline purgative, should be administered twice or thrice daily for a few days in succession, T. S. COBBOUJ. ASCITES (ia-Khs, a leathern sac; a large belly). — Synok. : Dropsy of the peritoneum ; Hydrops peritonei vel abdominis; Hydroperi- toneum. Fr. Ascite ; Qer, Die Bauchwassersucht. Definition. — An accumulation of fluid within the cavity of the peritoneum, more or less serous in character, the accumulation being of the nature of a local dropsy, and not originating in inflammation. The amount of fluid varies much in different cases. .aiTioiOHT AND Pathologi. — The chief mattei ASCITES. 88 relating to the causation of ascites is to point out the morbid conditions by whieh it may be produced, as it almost always follows, and is a consequence of certain pre-existing organic diseases, of whicli it becomes a most important symptom and pathological phenomenon. The causes to which it has been attributed may bo discussed according to the following arrange- ment : — I. Direct mechanical obstruction affecting the portal circulation. 1. Obstruction of the trunk of the portal vein before it enters the lirer, either from external pressure or internal obstruction. 2. Pressure upon or obliteration of the branches of the vein within the liver. 3. Pressure upon the trunk of the hepatic vein, or upon the inferior vena cava after it receives this vein. II. Cardiac or pulmonary diseases obstructing .he general venous circulation. III. Disease of the kidneys. IV. Morbid conditions of the peritoneum, v. Miscellaneous. I. Any direct obstruction interfering with the portal circulation must necessarily lead to congestion and over-distension of its tributaries, one of the consequences of which is exces- sive transudation of the fluid portion of the blood into the peritoneal cavity, while absorption is checked. The ascites is, under such circum- stances, in short, merely a localised dropsy, resulting from mechanical congestion. The impediment may affect either the portal trunk before it enters the liver ; its branches in the substance of this organ ; or the hepatic vein or inferior vena cava near its termination. 1. The portal trunk may be pressed upon as it lies in the fissure, by prominences from the liver itself, enlarged absorbent glands in its vicinity, a neighbouring tumour (as cancer of the pancreas or a growth in the small omentum), a hepatic aneurism, or inflammatory thickening resulting from peri-hepatitis. The pressure may absolutely close up the vessel, but it more com- monly causes a, local clot to form, and thus its channel is blocked up. A thrombus is also in exceptional instances produced in connexion with a diseased condition of the portal vein, such as inflammation or calcification ; obstruction to the circulation within the liver ; or feebleness of the circulation, with an abnormal tendency to coagulation of the blood. 2. Pressure upon, or obliteration of the branches of the portal vein within the liver, can only arise as a consequence of some morbid condition involving the actual substance of this organ. The hepatic disease which by far most commonly leads to this result, and which is one of the most frequent causes of asciteSj is cirrhosis. Occasionally it accompanies syphi- litic and other forms of contracted and indurated liver) or it may be' associated with infiltrated cancer. The extent of the obstruction thus set up will necessarily vary with that of the morbid changes in the organ. Occasionally a mass within the liver obstructs a considerable branch of the portal vein. 3. Obstruction of the hepatic vein or inferior vena cava is a rare event, but may. arise from the pressure of a growth connected with the liver itself, or of some neighbouring tumour. II. Diseases of the lungs or heart which impede the general venoiis circulation musL necessarily exercise a speedy and direct in- fluence upon the hepatic circulation, and may thus lead to ascites. Usually, however, in cases of this kind the legs are the seat of considerable anasarca before peritoneal dropsy is observed. In course of time the continued congestion ori- ginates serious organic changes in the liver, its vessels being more or less obliterated, and consequently it is at this period that ascites is particularly liable to set in. ' III. Ascites may constitute a part of the dropsy which so often accompanies renal diseases. It is, however, of comparatively infrequent occurrence to any great extent under these circumstances, the amount of fluid being not considerable as a rule, and the ascites being biit a subsidiary part of a general dropsy. IV. More or less serous effusion into the peritoneal cavity is a pathological result of peritonitis ; but, in accordance with the defini- tion of ascites given above, this does not come strictly within the present article. In excep- tional instances, however, true ascites is observed as a sequel of peritonitis, in consequence of the morbid conditions which it leaves behind. Chronic peritonitis may also occasion a simple local dropsy ; but this is particularly liable to be set up in connexion with morbid formations in the peritoneum, such as cancer or tubercle, of whieh the writer has seen striking examples. The immediate causes of ascites associated with diseases of the peritoneum may be : — active congestion ; implication of the capillaries or minute veins, or even of the larger veins, lead- ing, to mechanical congestion ; obstruction of the lymphatic orifices, and consequent impaired absorption; or undue activity of the secreting structures. V. Among the chief misceUaneous causes to which ascites has been attributed may be men- tioned exposure to cold or wet ; the sudden sup- pression of habitual discharges, or the rapid cure of chronic cutaneous affections ; and extreme ansemia and debility. These causes are supposed to originate this symptom either by inducing active internal congestion ; or by disturbing the renal functions ; or in consequence of the abnormal state of the blood and tissues ; butitis very doubt- ful whether either of them can actually of itself occasion ascites. Pluid may collect within the peritoneum as the result of the rupture of a cyst within the abdomen, especially an ovarian cyst. It must be remembered that ascites may be due to a combination of two or more of the causes which have been indicated in the pre- ceding remarks. For instance, there may be obstruction affecting the portal circulation within the liver and outside this organ at the same time ; or the different organs may be in- volved simultaneously. Predhposing rawes.— Whatever tends to set up either of the morbid conditions which originate ascites, may be regarded as a pre- disposing cause. It may be met with at any age, but is most common during middle life. The hepatic form is much more flreCLueut iu 34 ASCITES. males than females. An aniemio condition of the blood and -weakness of the tissues- predis- pose to peritoneal dropsy, as they do to dropsy in other parts. Anatomical Chabaotebs. — The essential ana- tomical character of ascites is the accumulation of a serous fluid -within the peritoneal sac. Its amount may range from a few ounces to some gallons. As regards physical characters, the fluid is generally thin, limpid, and -watery in consist- once ; colourless or slightly yello-w ; clear and traasparent ; and of allSiline reaction. In ex- ceptional instances, however, it may be coloured by blood or bile ; or more or less turbid and dirty-looking; or of thicker and somewhat gelatinous consistence. Soft fibrinous masses occasionally float in the fluid, or these may form spontaneously when it is allo-wed to stand. Very rarely the reaction is neutral or acid. The specific gravity varies considerably. Chemically the fluid consists of water holdingin solution al- bumin and the usual salts which are found in drop- sical fluids ; but their proportion is very variable, though the albumin is generally in good quantity, whici is evidenced by the degree of coagulation which takes place when the fluid is boiled. Occasionally it contains fibrin, cholesterine, bile- elements, or, incases of renal dropsy, urea. The effects of the accumulation upon surround- ing structures are to distend and macerate them more or less, or to compress them. Of course along -with the ascites there -will be the signs of any morbid condition upon which it depends ; and there may also be indications of anatomical changes resulting from long-continued pressure of the fluid upon certain structures. Symptoms and Slows. — Ascites usually sets in very gradually, being chronic in its progress, but advancing steadily. Occasionally, however, the fluid collects with considerable rapidity. The clinical phenomena associated -with this patholo- gical condition differ in different cases, both in their exact nature and their degree, according to its cause, the amount of the fluid, and other circumstances, but they may conveniently be considered under the folio-wing heads, namely : — \. Physical si^ns. 2. Meohanical effeets of the dropsical accumulation,. 3. General symptoms. 1. Physical Signs. — ^Physical examination con- stitutes a most important part of the clinical investigation of cases of ascites, and it -will be requisite to discuss the signs in some detail. (a) If fluid collects in the peritoneum in any quantity, the abdomen presents more or less general enlargement. This is often the first change which attracts the patient's attention, and it may also have been noticed that the increase in size commenced belo-w. The degree of en- largement depends upon the amount of fluid, but it may become extreme, so that the skin is ti^tly stretched and thin, presenting a smooth and shining appearance, or sometimes white lines are visible, due to laceration of its deeper layers. The umbilicus becomes affected in a character- istic manner, being more or less stretched and everted, and finally becoming obliterated, or in some cases more or less pouched out, and it may form a considerable prominence. Should there happen to be a weak portion of the abdominal w^ls, such as a hernial sac, this will be unduly pro- truded. The important characters of abdominal enlargement due to uncomplicated ascites are that it is of a rounded form, though tending to be more prominent or to bulge towards the lower part or in the flanks, according to the posture of the patient; that it is quite symmetrical in shape, when the patient stands or lies on hig back, but that the form alters considerably with a change of position, the abdomen becoming then more prominent in the dependent region, in con- sequence of the gravitation of the fluid in this direction, and it may actually ' be seen to move as the posture is changed. ' In contrast -with the enlarged abdomen, the eheSt often looks small and depressed, and the fluid may cause its margin to become everted, or it may push for- wards the xiphoid cartilage. (6) The abdomen feels perfectly smooth and even, over its entire surface. It usually gives a sensation of tension of the walls, -without any hardness underneath. In some instances an obscure feeling of fiuctuation is experienced on palpation with the fingers. (c) The tendency of ascites is to interfere -with the abdominal respiratory movements, if it is at all considerable, by preventing the diaphragm from acting properly. At the same time the -writer has not uncomnionly observed that, even in cases where the accumulation of fluid has been very considerable, abdominal respiration did not seem to be much diminished. {d) Percussion affords some of the most im- portant signs of peritoneal dropsy ; and when the fluid is present only in small quantity, this is the only mode of examination that can lead to its detection. In the first place marked dulness is elicited over the seat of the fluid ; while a tympanitic sound, which is often abnormally clear and distinct, is heard over the intestines. When there is but little fluid, it may be im- possible to detect any abnormal dulness as the patient lies in the recumbent posture, b-flt on placing him on his hands and knees, the fluid gravitates towards the front of the abdomen, and dulness may then be noticed in the um- bilical region. In most cases, however, there is no difSculty in making out the dulnesS, and this sign is observed in those regions towards which the fluid naturally gravitates. Hence, when the patient lies on his back, the lower part and sides of the iabdomen are dull, while its upper and front part is tympanitic. As more and more fluid collects, so the dulness increases in extent, gathering in, as it were, from below and from the sides, until finally the entire abdomen may be dull, except the umbilical region, which remains longest tj'mpanitic. The boundary line between the dulness and tympanitic sound is usually well-defined. As the posture is changed.so ■will the site of the dulness vary, the part which is undermost presenting this sign, while that which becomes highest is tympanitic ; and thus the relative' situation of these two sounds, as well as the shape of the dulness, can be altered in a variety of ways. When the patient sits ilp, the prominence between the recti muscles gives a tympanitic sound on percussion. In exceptibiial instances a distended colon gives rise to a tym- panitic sound along each side of the abdomen, even when there is abundant fluid present. ASCITES, 86 Another important sign brought out by a kind of percussion is the sensation specially termed fiuctuatwrii which is the peculiar wave-like move- ment realised on placing the fingers of one hand over one side of the abdomen, and fillipping or tapping the opposite side with the fingers of the other hand. This sensation is very easily brought out if there is much fluid present, pro- vided it is free to move, and sometimes the motion is actually visible. Change of posture will modify the seat over which fluctuation can be produced. (e) Ausaultation yields negative results in cases of ascites, there being no sound of any kind heard over the abdomen. (/) In the large majority of cases ascites is clearly revealed by the physical signs already iesoribed. In exceptional instances, however, when the diagnosis is obscure, it is requisite to resort to a digital examination through the rectum, and in females through the vagina. The fluid collects in the recto-vesical pouch, and on examination per rectum, the finger detects the sensation of this fluid through its anterior wall, The vagina is usually felt to be shortened, while the uterus is pushed down and flexed. In ex- treme cases of ascites the posterior wall of the vagina, or even the uterus itself, may protrude ■Jirougii the vulva. (g') Now and then it is requisite to make use of the aspirator or a small trochar, by the aid of which not only can it be determined whether fluid is present in the abdominal cavity, but its nature can also be ascertained. This method of examination is further useful when ascites is associated with some other morbid condition within , the , abdomen, which frequently cannot be made out so long as the fluid remains in the peritoneum. It must be borne in mind that the ordinary physical signs of ascites will be materially modi- fied or obscured under certain circumstances. For example, the quantity of fluid may be so small that most careful examination is required in order to detect its presence; on the other hand, it may be so abundant that dulnesa is observed over the entire abdomen, and fluctua^ tion may be very indistinct. The existence of peritoneal adhesions — for instance, those which may be formed as the result of repeated para- centesis — also renders some of the most charac- teristic signs of ascites very Hi-defined. Again, the association of peritoneal dropsy with some other abdominal morbid condition, such as a new growth, an enlarged liver or spleen, or an ovarian tumour, will also modify the signs elicited. The mesentery maybe abnormally short, or the in- testines may be adherent, thus being prevented from fioating forwards, so that the usual relative positions of dulness and. tympanitic sound are not observed. 2. Mechanical effects of the dropsical accumu- lation. — The clinical phenomena resulting from the mechanical effects of astites are hothsub- jeotive and objective. The patient often expe- riences a feeling of uneasiness and discomfort in the abdomen, as well as more or less tension and fulness, if there is much fluid present ; while there may be a sense of fatigue and aching about the loins or abdominal walls. As a rule no particular pain is felt, but colicky pains are liable to occur from time to time, and extreme distension of the structures constituting the abdo- minal wall may also cause painful sensations, In exceptional instances peritonitis is set up. When the fluid is abundant, the patient expe- riences its weight when he walks, and, during this act, he throws the head and shoulders back, at the same time keeping the legs apart. Symptoms connected with the alimentary canal are of com- mon occurrence, but these are often to a great extent due to the same cause which originates the ascites, though the fluid must necessarily tend to interfere with the functions of the stomach and intestines. The bowels are usually constipated, but in some instances diarrhoea or dysenteric symptoms may arise. Flatu- lence is very commonly complained ,of, even a small amount of gaseous accumulation in the intestines being felt unduly, producing much discomfort, and increasing the enlargement of the abdomen temporarily. Occasionally vomit- ing occurs, in consequence of interference with the_ stomach. When considerable fluid has re- mained in the peritoneum for some time, it presses upon the inferior vena cava and prevents the return of blood through this vessel, and may thus lead to anasarca of both lower extremities, with enlargement of the superficial abdominal veins. .Exceptionally the anasarca attracts atten- tion at an early period. The flow of blood through, the renal veins may also be obstructed,, inducing mechanical congestion of the kidneys, vfith consequent diminution in the quantity of urine and albuminuria. In rare instances the fluid has been known to accumulate to such an extent as to rupture some part of the abdominal walls. Ascites also frequently interferes with the thoracic organs. The bases of the lungs are more or less collapsed, and the breathing :beeomes chiefly upper-costal, while a sense of dyspnoea is experienced, especially in the recumbent posture and after taking food, the breath is shqrt on exertion, and the respirations are often hurried and shallow. The heart is likewise liable tobe disturbed in its action, as evidenced by palpitation, irregularity, or a tendency to faintness. This organ may also be displaced,- so that its apex-beat is raised and too far towards the left, and in rare instances a basic systolic murmur has been originated as a result of this displacement. 3. General symptoms. — The general system is frequently, seriously affected in cases in which ascites is a prominent symptom, but this usually depends upon the cause or causes which have originated the dropsy, though it may itself in- duce more or less debility, wasting, ansemia, and other general efiects. The loss of fluid in this way has also been supposed to lead to defleient perspiration, andconsequent dryness of the skin; as well as to diminution in the quantity of urine! Diagnosis. — The first matter bearing upon the diagnosis of ascites is to determine whether this morbid condition actually exists. The presence of fluid in the peritoneum, as well aa its amount, can only be positively made out by physical examination, and in the great majority of cases the. signs thus elicited are quite charao- 66 ASCITES. terlstie. When the fluid is small in quantity, as -well as under other circutastances in whieh the physical Signs are obscured or modified, the diagnosis ma,y be difficult and uncertain, but it may then be aided by a knowledge of the ex- istence of some disease likely to give rise to ascites. That the accumulation of fluid is of a dropsical nature, and not due to acute or chronic peritonitis, is usually sufficiently obvious from the history of the case, and the collateral symp- toms, while the local signs are also of a different character (see Peritoneum, Inflammation of). The remaining abdominal enlargements from ■which ascites has to be most cottimonly distin- guished are those due to flabby relaxation of the walls of the abdomen, combined with flatulence ; accumulation of fat in the subcutaneous tissue and omentum ; abundant subcutaneous oedema, which may be associated with and obscure ascites ; an ovarian tumour ; or a pregnant uterus. _ Among the rarer conditions with which ascites is liable to be confounded may be men- tioned colloid disease of the omentum ; a greatly dilated stomach ; distension of the uterus with fluid ; great accumulation of urine in the blad- der ; a very large hydatid tumour, usually con- nected with the liver ; extreme cystic enlarge- ment of the kidney ; and the so-called ' phantom himour.' Most of these conditions are described in other parts of this work, and the limits of this article forbid any discussion of their several diagnostic characters ; but a consideration of the history and existing symptoms of the case, com- bined with the results of a proper physical exami- nation, constitute the data upon which the diag- nosis is founded. It must be remembered that ascites may coexist with other morbid con- ditions in the abdomen, their physical signs being combined. Should there be an enlarged organ or other solid mass, it may often be recognised by making sudden firm pressure with the fingers over the abdomen, when the fluid is pushed aside, and the underlying resistance can be felt ; or paracentesis may be performed, and further examination carried out after the evacuation of the fluid. Another most important point in the diagnosis of ascites is to make out its cause. For this purpose all the facts bearing upon the case must be taken into account and carefully weighed, special attention being paid to the liver and the structures in its vicinity, to the heart, and to the kidneys. The amount of the ascites, and its relation to other forms of dropsy, aflford consider- able aid in the diagnosis. If it results ffom cardiac or renal disease, ascites always follows dropsy in other parts of the body, to which it is also generally subordinate; when it is due to hepatic or some neighbouring disease, the peri- toneal dropsy appears first, and is throughout most prominent. Should the vena cava inferior be obstructed at its upper part, anasarca of the legs will be observed simultaneously with, or even before the ascites. Prognosis. — The prognosis of ascites will mainly depend upon its cause ; the amount of fluid present ; the state of the patient ; the condition of tlie main organs ; and the results of treatment. In some cases this symptom is in it- Bolf attended with immediate danger, on account of the mechanical effects of the droijsical accumu- lation, especially upon the thoracic organs, and still more if these organs are in a diseased condi- tion. In other instances it aids in reducing the patient, and in thus bringing about a fatal ter- mination. When ascites is due to local inter- ference with the portal circulation, great reliel can unquestionably be afforded in a considerable number of cases, and life may be prolonged by appropriate treatment ; while, if the local cause is not such as in itself to lead to a fatal issue, the ascites may not infrequently be permanently cured. Tbeatjtbnt. — The principles of treatment ap- plicable to cases of ascites are (o), to attend to the condition upon which the dropsy depends, and thus endeavour to get rid of its cause ; (i) to promote the absorption of the fluid; (c) to im- prove the constitutional condition and the state of the blood, if necessary ; (d) to remove the fluid by operation, if absorption cannot be ac- complished ; and (e) to treat any symptoms need- ing special attention. (n) As an important part of the treatment directed to the cause of ascites, particular atten- tion must be paid to those organs which are most commonly accountable for this symptom, though unfortunately in a large proportion of cases but little effect can be produced upon the dropsy in this way. (&) Absorption of the fluid is chiefly promoted by acting freely upon the bowels, skin, or kidneys. The class of remedies indicated will vary in different cases, and must be adapted to the state of the different organs, but as a rule active pur- gatives are most efficient in relieving ascites, especially when due to local causes, of which the most useful are compound jalap powder, cream of tartar, elaterium, calomel, gamboge, podo- phyllin, and eroton oil. These remedies must, however be used with due caution. In some instances balsam or resin of copaiba has proved useful in the treatment of peritoneal dropsy. Assistance may be derived in certain forms of ascites from acting upon the skin by means of various diaphoretic baths. Digitalis and squills may be of service as diuretics ; or the application of poultices of digitalis leaves over the abdomen is occasionally attended with benefit. The administration of iodide of potas- sium also seems to aid absorption in some oases. (c) Treatment directed to the general condition of the patient, and to the state of the blood, is undoubtedly valuable in many cases of ascites. Tonics are often of decided service, and prepara- tions of iron are specially indicated for im- proving the quality of the blood, if there is any tendency to ansemia. Not only do these remedies sustain the patient, but they may also have an influence in promoting the process of absorption. The diet must be adapted to the circumstances of the case, but usually needs to be of a nutri- tious character. (d) In a considerable proportion of cases, however, no effect is produced upon the dropsical accumulation by any of the measures thus far considered. Then it becomes necessary to de- termine whether it is desirable to remove the fluid by operation. The fluid may be taken away either by means of the aspirator, or by the trochar and canula. The advisability of ASCITES. hariug lecourse to this ■plan of treatment must depend upon circumstances. The ascites is fre- quently not sufB.ciently abundant to justify paracentesis, and wlien the condition is of cardiac or renal origin, tlie operation can only afford temporary relief, so that there is no' object in resorting to it unless the mechanical effects qf the accumulation are such as to cause trouble- some Qi; dangerous, symptoms, and it had better be delayed as long as possible. When ascites is a local dropsy, the fluid is oftefi so considerable in amount as to necessitate its removal for the mere purpose of giving relief for the time. Iii cases of ascites associated 'with malignant disease, for instance, this is all that can be hoped for, as the fluid -will certainly collect again. When, however, the condition is due to some lopal disease ■which is not in itself fatal, and especially to cirrhosis of the liver, the writer has found signal benefit result from the repeated performance of paracentesis, and has advocated this plan of treatment as a curative measure, so far as the OS cites is concerned. Barely does the operation give rise to any immediate ill-effects, and it is frequently found that remedies will act much more efliciently after the removal of the fluid than they did previously. In the writer's experience paracentesis repeated as often as the fluid re-accumulated has ultimately led to a complete cure in several instances; in others the cure was partial, a certain quantity of fluid remaining in the peritoneum, limited by ad- hesions; while in others still, life has been greatly prolonged, and much comfort afforded. The repeated accumulation does not seem to affect the system materially , by reason of the drain upon it, and frequently not at all. Of course due care must be exercised in the per- formance of the operation, and in the subsequent treatment. In a few days after the reraoval of the fluid, the application of a bandage firmly round the abdomen, so as to exert even pressure, may prove of service in aiding the absorption of what remains, and preyonting the recurrence of the ascites ; and this measure may also be useful when a certain amount of fluid continues after the repeated performance of paracentesis. (e) The symptoms resulting ftom ascites which are likely to require attention are those con- nected with the alimentary canal ; dysp^^a ; and cardiac disturbance, or a syncopal tendency. These should be treated on ordinary principles ; but it must be observed that marked dyspnoea, if evidentl^^ due to the fluid, is an indication for the immediate performance of paracentesis, FEEDEEICli T. BOBEBIS. ASIATIC OHOIiEEA. See Csojxsa. ASPHYXIA (4,.priv., and fftjii^ts, pulse).— Synon. : Apnoea; Fr. Asphyxie; Ger. Er- sticjeung. Definition. — The term Aspht/xia, though lite- rally signifying ^jifoefesOTesa, is generally under- stood to mean the condition that supervenes on interruption of the function of respiration. The term Apnaa, preferred by many as a more exact one, has the disadvantage of being employed by physiologists in a .totally different sense, viz, the cessation of the respiratory movements conse- quent on artificial hyperoxygenation of t he blood. ASPHYXIA. 87 There is therefore no advantage to be gained by substituting the term apnoea for the well- understood and older one, asphyxia. iEnoxoai. — Asphyxia may result from many causes which obstruct or interrupt the respira- tion. They may be divided into two categories, internal and external. Internal. — These include paralysis of the re- spiratory nerve-centres by disease or ii^jury of the medulla oblongata; paralysis of the nerves or muscles of respiration; a rigid fixation of the respiratory muscles; collapse or disease of the lungs ; occlusion of the air-passages by organic disease or spasm of the glottis, pressure o1 tumours, and the like. ■ External. — To this group belong occlusion of the air-passages by foreign bodies ; pressure on the chest not capable of being overcome by the muscles of respiration ; closure of, or external pressure on, the air-passages, as in suffocation, strangulation, or hanging. These are all cases of obstruction of the respiratory movements in a medium capable of supporting life. To these external causes are to be added those conditions in which, though the respiratory movements are free, the surrounding medium is incapable of oxygenating the blood, viz., submersion in a liquid medium (drowning) ; or being surrounded by a medium devoid of oxygen, such as ni- trogen or hydrogen. These gases have a purely negative effect ; but many other gases which are classed as asphyxiants, such as carbonic oxide, sulphuretted hydrogen, chlorine, chloroform va- pour, etc., have positive poisonous effects, and should therefore be called by some special name, such as toxic asphyxiants, to distinguish them from those which have no such properties. Phenomena. — When an animal is placed in an atmosphere deroid of oxygen, or not contain- ing a sufficient quantity of this gas (under 10 per 'cent.) to maintain the respiratory process, or if the mechanism of respiration is simply obstructed, it begins to show signs of agitation and to make powerful inspiratory and expiratory efforts, in which the accessory muscles of re- spiration are all brought into action ; the arterial tension increases ; and the superficial veins be- come distended and livid. After a variable period these dyspnceic efforts pass into general convulsions, in which the mus- cles of expiration are more especially in action, during which the sphincters are farced and the excretions voided. On these there follows a calm, during which the animal lies insensible, with dilated and immovable pupils, and with reflex excitability abolished generally. All muscular movements cease except those of in- spiration, which are repeated at intervals. As death approaches the respiratory movements become shallower and less regular, and are suc- ceeded by stretching convulsions, during which the back is straightened, the head is thrown back, the mouth gapes, and the nostrils dilate. The heart still continues to beat after other movements have ceased. The heart ultimately stops in the state of diastole. Death is then complete and final. OouESE AND Termination. — The time neces- sary to bring iibout a fatal termination varies in different animals, and in the same animal under 38 ASPHYXIA. different conditions. It has been noted that the young of some animals resist asphyxia longer than the adults. Paul Bert has shown that these differences are all explicable in accordance with the law that the more actiye the vital combustion, the greater the gaseous interchange, and therefore the more rapidly fatal the obstruction of the re- spiratory process. Excluding special considera- tions of this kind it may be stated as the result of the experiments ofthe Medical and Chirurgical Committee on Suspended Animation {Med.-Chir. Trans, vol. xly. 1862) that when the respiration of a warm-blooded animal is totally obstructed, all external moTements cease in from three to five minutes, and the heart stops within ten minutes. Certain modifications occur according to the method in which asphyxia is produced {see Dbowninq). Anatomicax Chaeactbks. — The blood is of a dark colour, owing to complete reduction of the haemoglobin, and the proportion of carbonic acid is greatly increased. Owing to the excess of carbonic acid, the blood coagulates slowly or imperfectly ; hence it remains long fluid, or forms few and soft coagula. The venous side of the heart, the great venous trunks, and the pul- monary artery are distended with dark blood ; while the left side varies, being sometimes full, more often perhaps either empty or containing a small, quantity of dark blood. The appearance of the lungs is not constant. These organs are by no means always congested, as is very generally stated, being more often pale and anaemic. The posterior and dependent parts be- come hypostatioally congested post mortem. The abdominal viscera are usually congested. The appearance of the brain varies, this organ being either anaemic of more or less congested. Spe- cial signs characterise special modes of causa- tion of asphyxia. Pathology. — Inasmuch as the cessation o'f re- spiration means both oxygen-starvation and accu- mulation of carbonic acid, the question is whether the phenomena of asphyxia depend on the one or the other, or on both. Various opinions have been entertained on this subject, but the experiments o-f Rosenthal and Pfliiger would seem to show that the deprivation of oxygen is the chief factor. That the accumulation of carbonic acid has no effect at all cannot, however, be maintained, for it is demonstrable that carbonic acid has a distinct toxic effect on living tissues. The circulation of non-oxygenated blood through the lungs and the respiratory centre in the me- dulla oblongata is the cause of the powerful respiratory efforts in the first stage — directly, by stimulation of the respiratory nerve-centres ; indirectly, by peripheral irritation of the pul- monary branches of the vagi. The respiratory movements increase in force, and the irritation irradiates into the centres of other movements besides those directly concerned in respiration, giving rise to the expiratory convulsions which have been ascribed by some to excitation of a special ' convulsion-centre ' {Krampfeenirum). The respiratory centres ultimately become paralysed, but subsequently to those of conscious activity — the brain; and of reflex action the spinal cord. The circulation of non-oxygenated blood like- wise causes contraction of the arterioles from irri- tation of the vaso-motor centre. Increased resist- ance is thus offered to the heart, and this is inten- sified by the convulsive muscular efforts. Tho arterial tension rises. The resistance to the flow through the capillaries by contraction of the minute blood-vessels occurs not only in the sys- temic, but also in the pulmonary circulation. Hence there is resistance both to the arterial and venous side of the heart. The ventricles become distended, and the heart's action laboured. The heart becomes enfeebled by the circulation of non-oxygenated blood in its walls, the diastolic intervals become longer, until the heart finally stops in a state of diastole, with the right side full, -while the left may have succeeded in empty- ing itself Treatment. — Besuscitation from pure asphyxia is possible so long as the heart continues to beat. After cessation of the heart's action treatment is unavailing, except in cases of cessation from mere over-distension, in which bleeding from the external jugular vein may be resorted to with success. The chief indication in the treatment of asphyxia is to effect oxygenation of the blood by the introduction of air into the lungs. If the medium by which the patient is surrounded is incapable of supporting respiration, he must be immediately removed, or the atmosphere changed. If the air-passage is obstructed by a foreign body, this must be extracted ; if this is impossible, oriftheobstructionresultfrom disease, tracheotomy or laryngotomy must be resorted to, Meansmustbe adopted of exciting the respiratory centres or respiratory muscles to action ; or if these are paralysed and non-excitable, the natural movements of respiration must be imitated arti- ficially, or air introduced by insufflation. The respiratory centres, if not absolutely para- lysed, may be excited reflexly by stimulation of cutaneous nerves, especially those of the face and thorax. This may be effected bythe stimulus of sudden cold, or better by alternate dashing of hot and cold water on the face and chest, or by flick- ing the skin with a towel. These reflex stimuli are often of themselves sufficient to excite respi- ratory movements; if not, they are powerful subsidiary aids to artificial respiration. The diaphragm may be stimulated to contraction by galvanisation of the phrenic nerve, one pole be- ing placed on the nerve as it crosses the scalenus anticus at the root of the neck, the other on the epigastrium. Chief reliance, however, is to be placed on the methods of artificial respiration, which, after all, are the most simple and the most effectual, and possessed of the pre-eminent ad- vantage of being always available. See Aetipi CIAL Eespibation. Air may also be introduced into the lungs di- rectly by properly constructed insufflatitm-appar ratm, either by the insertion of a tube within the larynx (an operation requiring dexterity, but without danger if skilfully performed, though there is always risk of rupture of the air-vesicles from over-distension) ; or more easily by the in- sertion of the tube in one nostril, the other nostril' and the mouth being closed (Richardson's apparatus). Mouth-to-mouth-insuffiation is some- times of advantage, especially in infants. Tho operator must close the nostrils of the patiqnt, ASPHYXIA. axi, applying his mouth directly to that of the patient, inflate the lungs by his own expiratory offbrts. The tendency to inflation of the sto- mach is considerably counteracted by backward pressure on the larynx. D. Fekbibe. ASPIBATOK. — SiNON. : Fr. Aspirateur. — The operation of Pneumatic Aspiration was intro- duced into practice b;}- Dieulafoy in 1869. Before this period various instruments had been used under the name of 'suction-trochars,' but to Dieulafoy is due the credit of fully appreciating their value. DESonrPTioii and Mode of Employment. — The aspirator consists of a glass syringe, having • at its lower end two openings provided with stop- cocks. 'When the piston is raised and the cocks are closed a vacuum is createdin the syringe, which can be maintained by fixing the piston' in the withdrawn position. An india-rubber tube is' fitted into each of the two openings, and these laust be provided with coils of wire inside to prevent them from collapsing. At the end of one tube is fixed a fine hollow needle. The needle should have only one opening, at the point, and not, as is often seen, another at some dis- tance from it. The instrument is thus used : — A vacuum having been created in the syringe by raising the piston whilst both stop-cocks are closed, the needle is introduced into the part to be operated upon. As soon as the opening of the needle is beneath the skin the stop-cock leading to it must be opened. The vacuum will then extend to the point of the needle; and conse- quently, if it' be gently pushed onwards the mo- ment it encounters fluid, this will jet up into the glass syringe, when its nature may be asoeiftained. This mode of operatingwith what Dienla'fby calls the ' previous vacuum ' is the essential differeftce between aspiration and suction. In aspiJation it is impossible to pass the needle through a collection of fluid without discovering it; whereas without the 'previous vacuum' in the'needle this might readily be done. If the fluid is sufficient in amount to fill the syringe, the stbp-cock lead- ing to the needle is to be closed and the other opened, by which the fluid may be discharged. The vacuum may then be re-established, and the operation- repeated as often as is necessary. By opening both stop-cocks at once and allowing the discharge tube to hang down, the aspirator may be converted into a syphon. The action of the instrument may ajsb be reversed, and it 'may be employed for injecting fluids. Other varieties of aspirator are in use besides the one above de- scribed. In Weiss's the receiver is a glass bottle, from which the air is exhausted by moans of a separate exhausting syringe. The objection to this is that if the needle becomes choked, it can- not be cleared by pushing down the piston and driving some of the fluid back through it. Other kinds of aspirator cannot be converted into syphons; and these are objectionable. Weiss's has the advantage of being less liable to get out of order, as the fluid does not touch the ex- hausting syringe. The needles employed vary in size. DieulaJoy recommends that they should be about A, ^, ^. and ^ of an inch in fiameter, and ' calls them Nosi 1, 2, 8, and 4 respectively. The aspirator may also be applied to trochars, ASPIRATOE. 89 but then its distinctive feature is gone, and it bedomes but a ' suction trochar.' The following rules must always be observed in using the aspirator. Ist.- Sea that the needle is pervious and clean and the syringe in order before using it. It is advisable ' to wash the needle well in strong carbolic acid solution. 2nd. The needle must be pushed straight on iil' one direction only. Its course must never be altered while the point is under the skin. If no fluid is found, it may be withdrawn and reinserted. It must be held as steady as possible during the aspiration. 3rd. If the fluid will not flow with the force of the vacuum, it is of no use squeezing and pressing the pa*t. This can only do harm. 4th. Aspiration must cease at once when blood comes in any quantity, especially in abscesses. Sth. Keep up the vacuum during ihe> withdrawal of the needle, lest some of the mbrbid fluid be left in its track. 6th. If the needle becomes choked, force a little of the fluid back through it in order to clear it. ' Uses. — ^Aspiration is used for purposes of diagnosis and treatment. Dieulafoy asserts that with the No. 1 needle it is possible to search for fluid without danger, whatever may be its seat or its' nature ; and experience has proved this to be practically true. In treatment it has been employed in the following afTections : — Abscesses. — In acute abscesses aspiration is usually of little value, as the pus soon re-accumu- latea< Jb chronic abscess connected with diseased bone it usually fails; and often it is impossible, from the amount of cheosy matter in the pus. In chronic abscesses unconnected with bone it some- times effects a complete cure aftbr three or four repetitions. It has proved successful in curing periuephritie abscess in the writer's experience. It is alvvays well in chronic abscesses Of do'ilbtful origin, to give this mode of treatment a trial. It must be remembered in treating large chronic abscesses that a dirty needle may lead to decom- position of their contents. Diseases of the Liver. ^-Hydatid cysts have been successfully treated by aspiration. In many cases the fluid becomes purulent after one or two aspirations, and iii some the cyst has opened externally. For pur- poses of diagnosis the small needles may alwayb safely be thrUst into the liver. Abscess of thb livtrhasbeensuccessfullytreatedbytheaspirator. Metention of WHne may always be safely relieved by using No. 2 needle above the pubes. ■ Ovarian cysts may be diagnosed and treated in the same way. Hernia. — It'has been asserted that stran- gulated hernia may be, in the great majority of cases, relieved by the use of the aspirator. The finest needles only should be used. They remove first the fluid from the sac, after which some gas may be obtained from the strangulated gut, but faecal taatter rarely fails to choke the tube. In this country surgeons have not succeeded in sufficiently emptying the gut to allow of its reduction. Expeijience has, however, 'shown that if the needle be kept steady, any 'number of punctures may be Safely made into the gut. Diseases of Joinisl — Aspiration is occasionally useful in' acute synovitis. Great care must be taken inot' to scratch the inside of the joint •with the needle, as this has been known to lead to acute arthritis and suppuration. No. 1 or 2 needle 30 ASPIEATOE. should be used. Hydrocephalus and Spina bifida may be aspirated with safety with No. 1 needle. In hydrocephalus it is to be passed through the anterior fontanelle. No case has hitherto Ijeen cured by this treatment. In Pleurisy and Ascites, except for purposes of diagnosis, in the writer's opinion the aspirator presents no advantages over a trochar properly constructed so as to exclude air (see Paracentesis). Pericarditis. — The operation of aspiration has frequently been successfully performed for pericardial effiision. It is thus carried out : — A spot is chosen 2 to 2J in. (5 or 6 centimetres) beyond the left edge of the sternum, in the 4th or 6th interspace. No. 2 needle is then passed obliquely, upwards and inwards, taking care to turn on the vacuum as soon as the eye is covered. The moment the fluid jets into the syringe the needle must be held steadily till the flow ceases. If this be done there is no danger of wounding the heart. If there is any doubt as to the existence of fluid, No. 1 needle must be employed, with which the heart may be punctured ■without great danger. MABcrna Seck. ASTHEBTIO/ («.pnT.,andhg is used to denote wasting in which the whole body participates. All acute diseases, if severe, are accompanied by emaciation, for at such times nutrition is temr porarUy interfered with. Jhe iise of the word 'atrophy' is, however, confined, as a rule, to cases where the interference with nutrition has been gradual, a,nd the loss of flesh consequently slow. .SliioLooy. — ^Atrophy is common enough at all periods of life. In infanta and children it is due, in the majority of cases, to chronic functional derangements which interfere with the digestion and elaboration of food. Less frequently it is a ATROPHY, GENERAL. 96 consequence of organic disease. In adults general atrophy seldom results from any other cause than organic disease, and functional disorder as a cause of serious wasting is the exception. In old age atrophy is a common consequence of the degenerations of tissue which accompany the decline of life. The interference with nutrition may, however, be aggravated by the presence of In infants under twelve months old there are four principal causes to which clironic wasting can usually be referred, namely, unsuitable food ; chronic vomiting (gastric catarrh) ; chronic diarrhoea (intestinal catarrh) ; and inherited syphilis. I3ad feeding, by setting up a chronic catarrhal condition of the stomach and bowels, is a frequent cause of both vomiting and diarrhcea, but it may produce atrophy without either of these symptoms. 'WTien an infant is fed, for instance, with large quantities of farinaceous matter— a form of food which is alike indiges- tible and innutritions — a very small part only can enter as nutriment into the system. The remainder passes down the alimentary canal, and is ejected at rare intervals in an offensive putty- like mass or in hard roundish lumps. The child, therefore, although overloaded with food, is really under-nourished, and loses flesh as long as such i a. diet is persisted in. If, as often happens, diarrhoea or vomiting be set up by the irritation to which the digestive organs are subjected, wasting is more rapid and the danger of the case is increased. Any form of bad feeding, and not only excess of farinaceous matter, will produce this result. Wasting, indeed, will be found in every case where the food selected is unfitted for the child, and thus it is not unfrequently seen in infants who are fed upon milk and water alone, The casein of cow's milk is difficult of digestion by many infants on account of its tendency to coagulate into a large firm clot like a lump of cheese. In this respect it differs from the curd of human milk, which forms light small floccu- lent coagula, and is digested without difliculty. Special preparation is therefore generally re- quired to reader cow's milk a suitable diet for a young chili It is not only, however, unsuitable food whit through the intestinal canal, because there has been no time for the bile-pigment to be absorbed into the blood. Or the fseces may be pale if they lie long in the bowel and the coloured matter absorbed. So that the colour of the stools is no sure sign of the poverty or abun- dance of the secretion of bile. In cases of pale- coloured fseces purgatives often do good, not because they have any special tendency to in- crease the flow of bile, but because they hurry the fseces out of the intestine, and thus give no time for the absorption of the bile, which, if it lay long in the bowel, would be absorbed, carried to the liver, and again excreted into the gall- ducts — the vicious circle of SchiflT. Nor is the analysis of the bile found after death in the gall-bladder of much value. Freriehi announced the presence of albumen in the bile in cases of congestion of the liver ; but it is now generally thought that this appearance is due ^solely to a post-mortem transudation. Eitter also has described a colourless bile in which all the constituents of bile are present except the pig- ■ ments. Most of his analyses were maide on bile taken from the gall-bladder after death ; but if the cystic duct be obstructed for any time, it is well known that the bile contained in the gall- bladder may become colourless without any real secretion of colourless bile having taken place in the first instance. It is impossible to be certain that the changes, which are found in the bile taken from the gall-bladder after death, have taken place during life. The only source of what may be called know- ledge of the disorders of the bile is observation of men or animals in whom biliary fistulse have been formed either by disease or by art. Unfor- tunately,:the majority of such observations have been physiological or pharmacological; and but few are recorded of the changes which the bile undergoes in disease. Altogether contradictory experiments are recorded of the influence of the nerves and of the diabetic puncture of the fourth ventricle -upon the secretion of bile. It is an admirable field for further research, but it -will be seen that our present knowledge very closely approaches to complete ignorance. It is disputed still whether the presence of bile in the stomach puts an end to the process of digestion. By many it is thought that the bile- acids throw down the albumen of the food, and with the albumen the pepsin. It is well known that in some disorders there is an inverted action of the duodenum, and bile is poured into the stomach, as in long-continued vomiting, for instance ; thus the dispute has a practical bear- ing. The best treatment of this state would seem to be by saline purgatives. Bile may also be taken up into the blood, and when this occurs, jaundice results (see Jathtdicb). J. WicKHAM Lego. BIIiHABZIA. — This name was given by the writer to a genus of flukes discovered by Dr. Bilharz, of Cairo, in the portal system of human BrLHAEZIA. blood-veSBelB, and the worm -was subseijiiently found by tha Tfriter in the portal vein of a monkey. This traematode hsematozoon -was first described as a Disioma, but the species is now more generally known as the BUharzia hamaiobia. It was ori- ginally found in the portal system, and Bilharz, Griesinger.Lautner.and others afterwards showed that this iparasite also infests the veins of the mesentery, bladder, and other parts, producing a formidable disease which is endemic in Egypt, at the Cape, at Natal, and probably in other parts of the AMcan continent, as well as in the Mauritius, The discovery that the endemic hsematuria of the Cape of Good Hope is occasioned by the presence of Bilharzia, is due to Dr. John Harley, who de- tected the ova in the urine of a patient who had previously resided in Southern Africa. Dr. Har- ley's impression that he had to deal with a new species of Bilharzia has not gained general acceptance, but he furnished proof of the wide geographical distribution of this parasite, .ind he also added largely to our knowledge of its ravages. Dbsokiption. — This parasite, unlike nearly all the other known species of fluke, has the sexes separate, the females being comparatively slen- der worms, resembling filariform nematoids. During copulation the female is lodged in a long slit-like groove, or gynoecophoric canal, with trhich the abdomen of the male is furnished. BILIAEY FISTULA. 107 no. i.^Bilharaa Itama- Fis. 3.— Ovmn o£ JHZ- t(Ma, male and female TMrzta hamatobia sexually combined. Mag- witli contained em- nifled. After KUohen- bryo and free sar- meiater. code-granules :xS31 diameters. Original. The eggs, measuring from M' to ^" in length, are peculiar, being either sharply pointed at one end, or furnished with a projecting spine, placed at a little distance from the hinder pole. This spine gives a point of resistance to , the egg during the struggles of the embryo to eflFect its escape. Those who are interested in the organi- zation of the ciliated embryos, and in the re- markable behaviour of the larvae during their earliest stages of growth, will find the subject fully discussed in the writer's paper ' On the development of B. hamatobia' together with remarks on the ova of another urinary parasite, occurring in a case of haematuria from Natal, Brii. Med. Joum., 1S72. Treatment. — The writer has pointed to' the danger of treating cases of Bilharzia as if they were comparable to ordinary helminthiases. It is neitlier desirable to employ active drugs for the expulsion of the parasite and its eggs from the bladder, nor is it prudent to attempt the employ- ment of vermicides with the view of destroying the worms. As in Trichinosis, so in the Bilhar- zia disease, it is essential to support the sys- tem. Thus tonics, cold bathing, and a highly nourishing diet, combined with the bicarbonate of potash and infusion of buehu, constitute our best resources when dealing with cases of endemic haematuria. The pathological facts clearly show that in order to effect a cure we must imitate nature herself as closely as we can. We must seek to erect artificial barriers, and thus check the haemorrhage as much as possible. For this purpose the writer has found the astringent properties of Arctostaphylos uva ursi eminently serviceable ; small quantities of hyoscyamus being usefully combined. Dr. Harley advises ' a perse- vering use of belladonna and henbane,' under the impression that treatment with these drugs ' will retard the development of the parasite, even if they do not effect its destruction.' The writer entirely disagrees in this view of the case, and he also objects to the employment of medicated injections. He thinks that the employment of diu- retics is likewise dearly coutra-indicated. Every- thing that will contribute towards allaying the vesical irritation, is certain to assist the natural process of cure ; and, in this view, the adminis- tration of buchu-iufusion, the enforcing of a liberal diet, and the taking of gentle exercise, will be found amongst the most important cura- tive aids. In bad cases a thorough cure is not likely to be completed until after the lapse of several years, Prophylactically it is essential to remove patients from the localities in which there is every reason to believe they have con- tracted the disease. In view, also, of preventing ^infection on the part of others, it is necessary that the water employed for domestic purposes throughout the infected districts, be rendered thoroughly pure by efScient filtration. For fur- ther particulars the reader is recommended to consult the general works of Kuchenmeister and Leuckart ; the writer's introductory treatise on Entoeoa (p. 197 etseq.); Dr. Harley's three separate memoirs (in the Transactwna of the Boyal Med. and Ghir. 8oc., 186i, &c.) ; and also especially the recent memoir by Dr. Sonsino, entitled ' Eesearches concerning Bilharzia hisma- toUa in relation to the endemic haematuria of Egypt,' with a note on a nematoid found in human blood ' {Bend, della B. Accad. delle Soimze, ^c, 1874). ;8ee also HzEMATozoA. T. S. COBBOID. BIIiIAEX OALOtriitrS. See Gall-stones. BILIABY FISTTJIiA.— There are two kinds of biliary fistula : — one, in which a commu- nication exists between the gall-bladder and the surface of the body ; the other, in which there is a communication between the gall-bladder and other internal organs. Neither kind is common, but the first is less rare than the other. In the first variety a tumour forms, sometimes in the place of the gall-bladder, at other times n ear the umbilicus, in the linea alba or to the left of this line, or in the groin. The tumour, if opened spon- taneously or by the surgeon, discharges a quantity of pus, bile, and gall-stones. If the cystic duct 1U8 BILIARY FISTULA. be obli ierated, no bile need escape. A suppura- tion of the gall-bladder, caused by the presence of gall-stones, is the common cause of these fistulse. The prognosis is good. The diagnosis, before the tumour opens, is very difficult. In a case ■which came under the writer's notice, it was mistaken for an abscess of the liver. In the second kind of biliary fistula, the gall- bladder may communicate with the duodenum or colon ; with an abscess of the liver ; with the portal or other abdominal vein, though it must be owned that cases of this kind seem somewhat dubious ; or with the urinary bladder, or at least with somepart of the urinary tract. Gall-stones are in nearly every case the cause of the fistulous opening. J, Wickham Ldqg. BIIiIOITS. — This term is used with much vagueness, and in popular language is often em- ployed very incorrectly, though the idea is to associate it with conditions in which an excessive formation of bile is supposed to occur. The chief uses of the word are as follows : — ^In the first place it is employed to designate a peculiar temperament — the bilious temperament. Again, individuals are often said to be bilious when they present a sallow or more or less yellowish tint of skin, but especially if they are distinctly jaundiced. Biliom vomiting and diarrhea signify respectively the discharge of a quantity of bile, mixed with vomited matters or with loose stools. Certain febrile diseases, attended with yellow- ness of the skin, are sometimes designated bHioiis fever, and under like circumstances pneumonia has been described as bilious pneumonia. Lastly, one of the most frequent applications of the term is to Certain so-called Uliovs attacks or biliousness, which, however, are commonly merely attacks of acute dyspepsia or migraine. The most prominent symptoms of a supposed bilious attack are anorexia, furred tongue, a bitter taste, sickness, constipation, and headache, with a feeling of marked depression and general malaise. Such attacks are most effectually pre- vented by careful regulation of diet, and the avoidance of exposure to cold, fatigue, and undue mental exertion or anxiety ; when they come on, abstinence from food is desirable, with rest in the recumbent posture, and perfect quiet. Altera- tive aperients and saline effervescents may be given, alcoholic stimulants being avoided as far as possible. Fkedehick T. Eobekts. BIIiIOUS TEMPEBAMEITT. See Tem- EEBAMEKT. BITTEB ALUOITDS, Foiioning by. See Pbussic Acid, Poisoning by, BIiACE VOMIT.— Vomited matters may 5e more or less black in different diseases, but ihe peculiar. J/ooA vomit is that which occurs in /ellowfever {see TEiiOw Fevbe). — The rejected matters are acid in reaction, and awdiment is deposited of coagulated albumen and dis- integrated blood-corpuscles. Ammonia is also present. The black colour of the vomit hius been attributed by some writers to altered bile, bjit there can be no doubt that it is, due to its ad- mixture with blood which has undergone certain changes. BLADDEB, Diseases of.— The bladder may BLADDEK. DISEASES OF. be the seat of the following morbid conditions :— Inflammation, acute or chronic ; Abscess ; Neu- ralgia; Atrophy or Hypertrophy; Mechanical Distension, with chronic engorgement and reten- tion of urine, commonly, but erroneously, termed ' Paralysis '; Sacculation ; Displacements, such as hernia in the male, or, very rarely, inversion and protrusion in the female ; Tumours or Growths, including fibrous, villous, or vascular growths ; Zpithelioma and Carcinoma; Tubercular Dis- ease ; Ulceration, either simple or malignant ; and Vesico-vaginal or Vesico-intestinal fistula. The bladder may also be the subject of true paralysis, partial or complete, as the result of injury to the brain or spinal cord, or following disease of those organs. Only a brief statement respecting the most im- portant of tliis class of affections need hs pre- sented here, in order to facilitate an acquaintance -with their diagnosis, since the treatment of almost all of them belongs to the province of the sm^eon, and so far only as it consists of medicinal reme- dies will the subject be considered. 1. Acute Inflammation — Acute Cystitis. — The mucous lining of the bladder is the part affected by inflammation — and although after long and severe attacks some morbid action oc- curs by extension to the muscular coat, or even to the peritoneal covering, these structures are very rarely affected. An acute inflammation of a very severe kind occurs from injuries; from the presence of instruments, foreign bodies, or calculi; and from unrelieved retention of urine. A less severe, somewhat evanescent, but very painful form of cystitis arises, from irritants taken internally, as cantharides. A ^tiU less severe, but often ' troublesome form originates by extension from gonorrhoea. In the frst class of cases there are not only severe local symptoms referable to the bladder, but the general system may be gravely affected. In the second class, of' which eantharides- poisoning is the type, the phenomena of very frequent, painful, and spasmodic attempts to eject small quantities of urine whidi is often bloody, _ occur within a very short time after absorption of the poison. A common blister is said to produce the affection in some persons. In two cases— the only two the writer has seen — it has followed the application of a blister to a surface already partially denuded of the scarf skin. In one of these a blister was applied to a knee which had been frequently painted with tincture of iodine, and was still slightly sore. In three hours after the application the patient was_ attacked with exceedingly painful efforts to micturate, which were at times intense. Theattack lasted six hours, gradually diminish- ing in force, and leaving no ill-effects behind. In less than twenty- four hours no trace of the symptoms remained. In the third form of cystitis, which is the most common, ajid of which that arising by extension from gonorrhoea may be taken as the type, the usual symptom's are undue frequency of mictu- rition; a necessity to perform the act imme- diately the' want has declared itself, a conditaon conveniently expressed by the single word 'urgency;' a desire to pass more, accompanied by pain, when all the urine has been voided ; and BLADDER, DISEASES OF. some dull aching over the pubes ; together -with a general febrile state of the system, often very Blight, but corresponding for the most part with the degree of local inflammation. The urine itself is cloudy, and deposits some light mucus on standing, but is not otherwise apparently altered. Under the microscope abundance of epithelium is -risible, as well as some pus-cells, and if the affection is severe, a few blood-cor- puscles are also present. It may be remarked here that the presence of a few pus-cells in iha urjne, a fact to which so many practitioners attribute considerable importance, by no means necessarily deserves to be so regarded. The very slightest attack either of this or of the pre- ceding form of cystitis is certain to ba attended by the formation of some quantity, however small, of fully-developed pus-cells. Very rarely a fahe membrane may be produced on the surface of the mucous membrane of the bladder, and may be thrown oflf almost entire, leading to the belief that the inner coat has itself been exfoliated. In women this membrane has been voided per urethram in a condition for ex- amination ; in men this cannot occur, because the urethra is too small to admit of it. Now and then examples of the former have been shown at the Pathological Society of London ; and one of the latter may be seen, discovered by operation, in the museum of the Eoyal College of Surgeons of London. 'StEiLTMENT. — ^In the first form of cystitis, the removal of the exciting cause, if possible, is the chief indication. The treatment of the second form should consist ofveryhot bidets or hip-baths, the former being probably preferable as capable of being used at higher teinperatures than the latter ; together with large doses of the tincture of henbane, say a drachm, with 10 or 15 drops of liquor opii every two hours while pain is severe; 20 minims of liquor potassae may be given either simultane- onsly or alternately, in water or in any bland diluent. The treatment of a well-marked case of the third class consists in absolute rest in the recum- bent posture, mild diet, abstinence irom all al- coholic stimuli, gentle laxative action of the bowels, and the administration of small doses of alkali. The writer prefers liquor potassse to all others, frequently repeated; and this may be combined with henbane, or, if micturition is very frequent and painful, with opium or morphia, or with chlorodyne in small doses. Hot hip-baths or bidets, followed by hot linseed-meal poultices or fomentations, give great relief. The patient may drink fireely of decoction of triticum repens, linseed tea, barley water, or similsi demulcents. Eelief rapidly follows, but care is reqnisite to avoid relapse, which easily occurs if exercise be taken too soon, if injections for the gonor- rhoea be resumed \ao readily, or if alcoholic stimulants are freely taken. 2. Chronio Inflammation — Chronic Cys- tltis.-^Chronic inflammation of -the bladder is separated from the acute form by very distinct characters. It is mostly the result of retained urine from stricture or enlarged prostate ; but it may ori^e &omthe presence of calculi i or of growths in the bladder ; from over-disteDsioD, ox atony of 109 its coats ; from paralysis after injury or disease aifeoting a nervous centre; from disease of neigh- bouring organs ; and sometimes from altered urine : it is also met with in certain affections of the kidney. Sometimes this condition is marked by the presence of a large quantity of viscous mucus, often called 'catarrh'; but mora com- monly this symptom is absent, and the virine contains merely ordinary mucus or muco-pus, rendering the secretion more or less cloudy and opaque. Perhaps there are some cases in which the inflammation is mainly due to the presence of gout. Symptoms. — The symptoms of chronic cystitis are increased frequency of micturition and pain, but the latter is by no means necessarily present. The urine is- always cloudy, and contains some pus-cells. There is often, but not always, some suprapubic uneasiness. The general health does not suffer unless the affection is prolonged or severe. If important causes, as the presence of stricture, calculus, &c., occasion the chronic cysti- tis, their specific symptoms will predominate. It is not common to find chronic cystitis as an idiopa- thic disease, although undoubtedly it occasionally is so ; so that the writer has always regarded it as a useful maxitn, 'When chronic cystitis is declared to be idiopathic, we may be sure that we have only not yet discovered the real cause.' As a general rule we may be sure that there is inability to empty the bladder, or calculus, stricr ture, or organic disease of some kind in some part of the Urinary tract, when the group of symptoms are present which we denote by the term ' chronic cystitis.' Eespeeting' the well- known glairy ' mucus, which is deposited so abundantly from the urine in some cases, in elderly people almost invariably, it should be said that it appears only in those whose urine is abnormally retained, through atony of the vesical walls, or in consequence of enlarged pro- state, or as the result of sacculation of the blad- der, and that medicine has little or no effect upon it. Tbbathent. — The regular and habitual use of the catheter, and perhaps also injections into the bladder, form the essential mechanical treatment of chronic cystitis in the cases just mentioned. In the few cases in which chronic cystitis is pre- sent, and no organic cause, such as those named above, can be discovered — and also as adjuncts to mechanical treatment when these causes dc exist — certain medvAnal agents are undoubtedly useful : these are buchu, triticum repenS, uva ursi, alchemilla arvensis, pareir^ brava, and the alkalis potash and' soda. Buchu is mora useful in subacute and recent chronic cystitis than in cases already of long duration. The patient should take not less than ten ounces of the in- fusion daily. After this, in similar cases, the decoction of triticum repens, made by boiling two to four ounces of the prepared underground stem in a pint or a pint and a half of water, of which six ounces should be taken' three or four times in the twenty-four' hours, is highly useful. For more chronic cases, where the urine is alkaline and deposits much mucus, and perhaps the triple phosphates also, alchemilla, uva ursi, and pareira brava may ba very_ valuable. The alchemill* is administered in infusion, one ounce of the no BLADDER, DISEASES OF. herb in one pint of boiling water, of which the dose is four to six ounces three times daily; the others according to the directions of the pharmacopceia. These may be taken alone or combined with potash, which in moderate quaati- ties diminishes the natural acidity of the \irina before it enters the bladder; the mucous membrane of which, although accustomed to that condition in health, is perhaps some- times, when inflamed, irritated by urine cf even the ordinary acidity. Whether thi^ be so or not, there is no doubt that alkalis do fre- quently tranquillise an irritable bladder. They are often given in the form of 7ichy water, Vals water, or that of Evian, all strong solu- tions of soda; but on many grounds the salts of potash are preferable. On the other hand, the mineral acids have been largely administered in cases where the urine is alkaline ; although there is no reason to believe that the acid has any direct action through the kidneys, or that it is eliminated by those organs. Alkalinity of the urine in chronic cystitis is almost always due to inability of the bladder to empty itself, and the remedy wanted is not medicine but a cathe- ter, at all events to ascertain whether this be the cause or not. A very small quantity of urine retained in the bladder, say one or two ounces, after every act of micturition, sufScos in some cases to maintain an alkaline and otherwise un- healthy state of the secretion: while it is equally true that some patients may habitually, and during long periods of time, do fail to empty the bladder, always leaving behind from half a pint to a pint, without losing the acidity of the urine. Of course other signs, and notably great frequency of micturition, are present when such is the ease. 3. Weuralgia. — It is impossible to deny that the bladder may be, like other parts of the body, subject to symptoms which are described as neuralgia, although the occurrence is an ex- tremely rare one. AH the writer can say is, that he has occasionally met with cases in which he has not been able to account, by the existence of any lesion, for pain and frequency in micturi- tion, or for diiflculty in performing that act, and where these symptoms havia ' been more or less periodic in their appearance. In such instances he has given quinine, and has occasionally found great relief to follow a few doses ; more frequently this has not been the case. But now and then the value of the drug has been so marked as to corroborate a belief in the existence of vesical neuralgia. It must be repeated, however, that examples of such phenomena are extremely rare. The writer has also employed arsenic on the same ground. It is invariably necessary to investigate the general health, as well as the habits and diet of the patient. This, perhaps, may be the place for stating that in all chronic and slight deviations from natural and healthy function in the urinary organs, it is essentially necessary to inquire into the state of the diges- tive organs, to correct by diet and by medicine when necessary any imperfect action oh their part, if possible. Constipation alone, when habitual, may produce considerable irritability of the bladder, so also may the unnecessary use of purgatives. A gentle, easy, and daily action of BliADDEE, DISEASES OF. the bowels, a healthy condition of the primary digestion, the absence of flatulence and distension after food, should be ensured as far as possible in all patients complaining of frequent, difficujt, or uneasy micturition; and many such may be com- pletely cured of so-called urinary affections by strict attention to these matters. The writer's strong convictions relative to this fact, grounded on innumerable experiences of its value as an aid in practice, led him nearly twenty years ago to ascertain the great value, for such patients, of Priedriohshall water, now so extensively used ; and more than ever he insists on the use of a mild and laxative regimen and diet in their manage- ment. 4. Where obstruction to the outflow of urine exists (stricture of the urethra, most forms of enlarged prostate,- other tumours, &e.), the muscular walls of the bladder become the seat of Hypertrophy, which is a condition of compen- sation, therefore, and not of disease in or by itself. But such changes in the interlacing mus- cular fibres existing, Saooulation readily occurs, by protrusion of the lining membrane between the bands so produced. On the other hand, most commonly when the prostate is hypertrophied, the bladder becomes gradually distended, its coats become expanded, thinned and weakened, and a certain degree of Atrophy takes place. The power of the organ to expel urine is lost or diminished ; and micturition being a function of simply mechanical nature, the circumstances 6f the case demand only a 'mechanical remedy, viz. the catheter. No medicine can restore power and exercise of function under these circimistances. But atrophy and loss of power may occur from complete. or partial loss of nervous influence to the bladder, as in those who are the subjects of paralytic states commehcing in the spinal cord or brain. When the paralyticstate' follows accident causing injury to a nervous centre, the nature of the case is obvious enough. But sometimes the onset and progress of chronic disease in these organs are very slow and insidious ; the urinary troubles, as manifested by slowness or difficulty in passing urine, or by urine clouded through inability of the bladder to empty itself, may be the earliest signs of the nervous lesion. On the other hand, impaired gait, and other evidences of central mischief, may be and mostly are earlier phenomena, the derangement in the urinary function appearing at a later stage. For suci patients, the habitual use of the catheter is often necessary [always of course when unable to empty the bladder by the natural efforts] ; while such constitutional treatment as is indicated by the cerebral or cerebro-spinal lesion present will compreihend that which the bladder demands. It is therefore unnecessary to allude further to that subject in this article. The same remark also applies to those few examples of Tubercular disease of theurinary organs, which is always a local expression of a general constitutional slate sufficiently considered under its proper head in this work. All other treatment of this malady is local and surgical. 5. Relative to Tumours, the varieties of which have already been enumerated, no medical treat- ment otter than that of chronic cystitis ia to bo thought of. BLADDER, DISEASES OF. With almost all affections of the hladder, simple or malignant, ulcerative or associated with fistula, cystitis to some extent and in some form co-exists. It is this -which gives rise to the presence of an undue quantity of mucus in the urino ; it is often the source of pus, sometimes of blood in small quantity. Thus in aU the^ ahove- mentioned diseases, some degree of cystitis ap- pears sooner or later. Hbsrt Thompson. BIiADDER-WOKMS.— Entozoa having the character of cysts or vesicles, and being at the same time more oi less transparent. This general term embraces a variety of parasitic forms, such as Echinococci, Ctenuri, and Ci/sti- cerci, all of which are the larvje of different species of tapeworm. Practically, it is impor- tant to know the origin of every kind of human bladder-worm, since the adoption of appropriate hygienic measures may prevent infection by each of the various species. See EcHiNococons, Cts- TiCEECUS, Hyiutids, Measle, T^nia, and TapBWOKM. • T. S. COBBOLD. BLAIIT. — A blister, as in the case of chil- blain. According to Mason Good, blains are ' orbicular elevations of the cuticle, containing a watery fluid.' BLEB. — A large vesicle or bulla, containing for the most part a serous fluid, as in pemphigus, erysipelas, or burns and scalds. See Bustbb. BIiENOBEHCEA, BLENOKKHAGIA (PKeyva, phlegm, and ^e», I flow ; fi\eyiia, phlegm, and pirymiiu, I burst out). These terms are most correctly used to express excessive flow of mucus &om any mucous siuface. By means of an afBx, the locality or nature of the discharge is ex- pressed: e.^'., blenorrhaa oculi, nasaUs,iirethralis, More commonly, however, and less accurately, blenorrhoaa is employed as synonymous with gonorrhcea in the male or female. BLEPHABITIS {P\i(l>apop, an eyelid). In- flammation of the eyelids. See Eyb and its Appendages, Diseases of. BIjEFHABOSFASM {P\4^apay, an eye- lid, and tririiriut, a spasm). Spasmodic move- ment or contraction of the eyelids. See Eye and its Appendages, Diseases of. BIiINSITESS. — Loss of sight. See AuAxr- Bosis, and Vision, Disorders of. BLI3TEB.— Synon.: Bleb; Bulla; 'Bi.Bulle; Ger, Blase. DEFiNrrioN. — A vesicle of the skin, caused by the separation of the horny cuticle from the rete mucosum by the transudation of serous lymph beneath the former. JEtioloby. — ^Blisters may be idiopathic, as in pemphigus; or symptomatic, as in erysipelas. They are met with under the influence of any cause which depresses the vitality of the integu- ment, as in some forms of prurigo, in chilblain, and in carbuncle; in scalds and bams ; and as an eflfect of powerful irritants, such as caotharides or the aniline salts. Desojiption. — A blister ranges in size from that of a pea to a turkey's egg ; it is more or less convex according to tie amount of exudation ; and conforms in colour with that of its contents, being sometimes yellow or amber-coloured and transparent, like serum, sometimes opalescent BLOOD, ABSTRACTION OF. Ill from the presence of pus, and sometimes red or purple from admixture with blood. The fluid of a blister, generally limpid and free, is sometimes held in the meshes of a delicate network, result- ing from the stretching of the connecting cells of the rete mucosum and horny epidermis. This is peculiarly the case in blisters developed under the influence of acute inflammation, and especially in Dermatitis anilina. Blisters may be dis- persed, or aggregated, or even single, as in Pem- phigus or Pompholyx solitarius. 1'beatment. — Blisters are essentially asthenic in their nature, and call for corroborant therapeu- tical treatment. Locally they should be punc- tured so as to admit of the gradual escape of their contents, and then dusted over with some absorbent powder, such as oxide of zinc, fuller's earth, or cinchona. Ekasmus Wilson. BLISTEBING-. — A therapeutic measure which consists in the artificial production of blisters on the skin. See Cotjnteb-ibeitation. BIiOOD, Abstraption of. — Synon. : Bleed- ing; Blood-letting. Fr. La Sqignie ; Ger, Ber Aderlass. — Definition. — The withdrawal of blood from the body, either (a) from the gene- ral circulation, by arteriotomy or phlebotomy ; or (6) locally, by leeches, scarifications, or wet- cuppmg. It is to the first two of these methods of abstracting blood that the term 'bleeding,' or 'blood-letting,' has by common usage been restricted. The topical abstraction if blood by means of leeches, scarifications, and capping, though often valuable, is of secondary importance. 'The pre- sent article will, therefore, chiefly be devoted to general bleeding. General Bleeding. — This art, practised for centuries more or less universally, has of late years in this country fallen into disfavour. Much discussion has been raised as to the grounds for so great a difference. It has been attributed — (1) to the type of disease having undergone a change ; (2) to mere fashion or caprice; (3) to a better knowledge of the nature of disease, teach- ing us that its processes were of a lowering or depressing character, which were to be overcome, not by the abstraction of blood, but rather by the use of stimulants and support. It is highly probable that several causes have contributed to the undoubted change which has taken place. The year 1830 and subsequent years were marked by the epidemic visitation of cholera and of influenza. These diseases were characterised byextremedepression. If antiphlogistic measures were adopted, they proved failures, and taught the physician that blood-letting was not the universal panacea it was supposed to be. By degrees it ceased to be practised as it used to be. A new generation which know not the past has sprung up ; and, as in all reactionary movements, the practice has become at length as limited as it for- merly was universal. It is almost certain that in either extreme there is an evil, and liat we may have recourse in certain cases to abstraction of blood with some degree of that success which formerly led to its extensive use, if not its abuse. It will bo well to consider the subject at some little length, and under the following head* : 112 1. The effect of moderate losses of blood on the healthy economy. 2. The value of bleeding as a remedy in dis- ease, together -with the indications for its employ- ment in various affections. 3. The method of performing the operations of opening an artery— arteriotomy; and opening a vein — ^phlebotomy, 1. Effects. — We have first, then, to con- sider the effect of moderate losses of blood upon the healthy economy. Upon tliis point we have abundant evidence, for the custom of regularly bleeding healthy people had reached such a point during the earlier half of this century that in country districts it became a practice for adults to be bled as regularly as they went to market. No better testimony regardingthe effects of this practice could be adduced than that of Sir James Paget, who, when referring to these customary venesections, says : ' I can regard those as a series of venesections fairly performed for the determination of what is the influence of the removal of blood up to the point of syncope upon a compdratively healthy person. I think I can say surely that not one of these persons suffered harm.' To this might be added other and abundant testimony to the harmlessness of venesection on the healthy eco- nomy. 2. Inbioations akd Uses. — Concluding, then, that the abstraction of a limited quantity of blood has no deleterious effect upon the healthy organ- ism, wo will next set forth the general indica- tions for the use of bleeding in disease, and briefly refer to the various affections in which it may most suitably be 'employed. Broadly stated it may be said that bleeding is indicated when there is evidence of marked over-distension either of the arterial or of the venous system. In either case the result will be cardiac distension — in the former case of the left, and in the latter of the right chambers of the heart. In such conditions general bleed- ing restores the lost equilibrium of the vascular system, and relieves the heart and the other parts concerned in the circulation of the blood. The arterial system may be in a state of aug- mented tension from two causes : (1) contrac- tion of the arteries (the smaller vessels) them- selves with a diminished amount of blood in the arterial system ; and (2) engorgement or dis- tension of the arteries from spasm of the arte- rioles : both may be regarded as vaso-constrictire neuroses. In the first case there may be engorge- ment of the venous system and embarrassment of the light heart, calling for abstraction of blood by venesection ; or visceral fluxion, the skin being pale : and in the second, relative emptiness of the veins with overfulness of the larger arteries, calling for blood-letting by aHerioiom^. In the former condition there would be, in bed-side language, a small hard or wiry pulse, and in the latter a full and hard or bounding pulse. In the former the surface of the body may present one of the two following con- ditions : either the skin is injected and, perhaps, dusky, and this appears to be the case ordinarily; or it is pale and cool, the blood having receded inwards, chiefly to the abdominal viscera. The second condition obtains and is well seen in BliOOU, AUS'l'ilAUTlUJN UJf. cases of uraemio asthma, when the arterial sys- tem is turgid almost to bursting, while the veins are comparatively empty. 'Hardness 'of the pulse is usually said to be an indication for bleeding, and in certain associations it is so; but it is necessary to discriminate carefully between the 'hardness ' due to ' tension' of the sound arteiy arising from (a) excessive con- traction (the small, hard, wiry pulse), and (A) overfulness (the full, bounding pulse) on , the one hand ; and that due to arterial degeneration with more or less hard deposit in the walls of the vessels, on the other. In doubtful cases inquiry should be made into the state of the brachial artery at the bend of the elbow. This can readily be done by flexing the limb, when, if calcareous degeneration have taken place, the vessel will be thrown into serpentine folds, visible, except in fat people, to the eye, and coid-like and rigid to the touch. The temporal artery is a less safe guide, but neither it nor an arcus senilis should be overlooked in this connexion, A visible and tortuous pulse in a young person may indicate aortic regurgitant disease : the age of the patient must therefore be taken into consideration. Dilatation of the arterioles would permit of the rapid passage of arterial blood into the veins : under such circumstances, therefore, we should expect the blood issuing from a cut vein to pre- sent a more florid appearance than under ordinary conditions. Bleeding here should be undertaken with considerable circumspection, and not be pushed very far, for collapse out of proportion to the amount of blood abstracted might ensue. On the other hand, when there is spasm of the arterioles, and the abstraction of blood is deemed advisable, it would be well to resort to arterio- tomy rather than venesection. The best guide here would be the sphygmograph, but, as few persons are yet accustomed to use it, the full, hard, boiiinding pulse must be relied on when found i n association with corroborative symptoms. Whatever leads to ovep-engorgement of either side of the heart may render bleeding necessary. If the left side of the heart be over-full, arterio- tomy is indicated; if the right, venesection. The object of the withdrawal of blood from, the general circulation is the direct relief of the overburdened heart. Whether the right or left chambers be taxed the immediate effect is the same ; they are over-distended, and cannot get a grip upon their swollen currents. It is with the embarrassed heart as with other hollow muscular organs-^-1ie bladder and uterus. Over-distension paralyses them by removing the 'points d'appui ' essential for the initiation of muscular contraction ; the energy may be there, but it cannot be exercised. It is obvious that the amount of blood which it is necessary to with- draw, in order to free the embarrassed organ, must vary considerably in different cases. But it may beeafely laid down as a rule that it need rarely exceed a few ounces. Excess in this respect is the evil which formerly existed. On this subject we may refer to the eminently practical remarks of Sir Thomas Watson, who ' says : ' I hold it, then, to be certain, that for some special morbid conditions, which inflammation may or may not accompany, general blood-letting, ' and especially venesection, is a potent and life- BLOOD, ABSTBACTION OF. presemng remedy ; that there are many exigen- cies for which it is not only safe to employ, but nusafe and unpardonable to withhold it.' He also gives the following judicious ad- vice : — ' Always it is necessary to consider the age, the sex, the general temperament and condition of the sick person, when we are turning over in our minds the expediency of abstracting blood. The very yonng, the old, the feeble, the cachectic, do not bear well the loss of much blood. This consideration is not to deter you from bleeding such persons topically when they are attacked by dangerous inflammation, but it especially enforces, in regard to them, the golden rule that no more blood should be abstracted than seems absolutely requisite to control the disease.' The following are some of the affections under which blood-letting would seem to be more or less indicated : — Pneumonia. — Blood-letting in pneumonia, as in many other inflammations, is most useful in the" early stages. It is indicated in healthy patients suffering from uncomplicated acute sthenic pneumonia, if they happen to be seen early enough. It relieves pain, abates fever, and if it does not arrest the disease, it certainly appears to lessen its duration. It may also be called for when there is severe pain and evidence of cardiac embarrassment. It did good, and will still do good, in cases of pneumonia, attended by embarrassment of the circulation, and that in truth is the indication for bleeding in this disease. Apoplexy. — The same may be said with re- ference to cerebral apoplexy. The old belief in the importance at 'letting blood' in cases , of apoplexy was, if possible, stronger than in cases of pneumonia. But here again more accu- rate clinical and more extended pathological knowled ge have tangh t us to look upon ' apoplexy ' very differently to our forefathers. Eecognising the escape of blood from the bursting of a brittle artery as a common cause of ' apoplectic fits,' we see the futility of venesection when the 'stroke' or ' fit ' is due to a lesion of this kind. Nor will bleeding unstop an artery when it is plugged by an embolus, or carry nutriment to the region thus bereft of vital fluid. On the other hand we have learnt to recognise the value of bleeding in another class of cases of so-called 'apoplexy' — those which are unaccompanied by effusion of blood or lesion of the nervous tissue, but depend on rapidly occurring com- pression of the nervous centres from sudden or unequal increase in the volume of any portion of the cranial contents ; or in certain eclamptic case; from the circulation of blood poisoned by uneliminated urinary excreta. In cases of this description, when the right heart and venous system are engorged, phlebotomy acts well ; the stertor will cease, the purple face resumes its natural hue, the clouded intelligence becomes clear, and tlie impending danger is for the time averted. This has not cured the patient, how- ever, it has only 'obviated the tendency to death:' it has saved the patient's life, though he may ultimately die of the disease which afflicts him. Where we meet with evidence of cerebral congestion accompanied by fulness of 8 113 the veins, a dusky countenance, and a ilow tall pulse, bleeding may most usefully be resorted to. In a word, although bleeding will not re- move the effttsed blood in cases of cerebral hiemorrhage, it may sometimes be usefully em- ployed to prevent further escape, when the heart is acting too forcibly ; but it is altogether forbidden when that organ is enfeebled. The pulse at both wrists should be attentively ex- amined before bleeding, in cases of cerebral haemorrhage, for as a rule it is larger on the paralysed than on the sound side. Eolampsia. — Indiscriminate bleeding in eclamptic seizures would be a grievous error. It would not relieve, but rather would probably intensify, convulsions of reflex origin, as in cer- tain cases of puerperal convulsions. On the other hand, cases of puerperal convulsions accompanied by great turgesconce of the vascular system, whether venous, (as is commonly the case) or arterial, would be immensely benefited by the withdrawal of blood from the general current, either by venesection or by ajteriotomy, accord- ing to the indication. This treatment may serve to stop the convulsions, and though that may be far from curing the disease, it may, neverthe- less, be of the utmost value, for in the first place the fits themselves may kill by their violence or frequent repetition ; whilst, secondly, time may be gained for the employment of other measures calculated to relieve the oppressed system, as, for example, purging by hydragogue cathartics, vapour baths, cupping the loins, &c. This gain may be immense ; for bleeding may avert impending dissolution. Moreover, per- manent good may ensue, inasmuch as bleeding reduces temperature, and in the eclampsia of pregnancy the temperature is usually high. In this it contrasts with pure urssmio convulsions, in which there is lowering of temperature. Venom Engorgement. — Engorgement of the venous system arising from chronic disease, e.g. pulmonary emphysema or heart-disease, does not call for bleeding, unless the condition be acutely intensified by some intercurrent mischief, such as acute bronchitis ; for, as the derangement is slowly produced, the organs aind structures in- volved learn to accommodate themselves more or less to the altered conditions. It is only when vascular engorgement suddenly occurs in appa- rently healthy subjects, or, as stated above, there is acute intensification of a chronic condition, that bleeding is required. Thus, in cases where mediastinal tumours impede the return of blood from the head and upper portion of the body, the condition is ordinarily of such comparatively slow production, that bleeding is seldom urgently called for; and, moreover, it would be of but small service, for the obstruction is irremediable The lividity of the face which accompanies all fits should not be confounded with the duskiness due to engorgement of the venous system gene- rally. Vrismia. — In pure ursemia bleeding is use- ful ; the kidneys being especially in default. Pop venesection answers a double purpose, by not only relieving the engorged right heart and venous system, but removing from the body a certain amount of poisoned blood— blood that is charged with urinary excreta. Doubtless, it does JiUUKJUi ^i.iiOA.ixjx.^±±yjj:i v/x. good in both ways, but the former is, quoad the fits, the more important because more imme- diate mode of its action. The second effect, that of ridding the body of damaged blood, is ob- viouBly available to us when we have to deal with uraemia, occurring in the non-pregnant; and when coma is deepening, the heart labouring, and the vascular system turgid, no remedy is so swift and sure as the lancet. Plethora. — Blood-letting may be called for in cases of general plethora, whether sthenic or asthenic. In the former condition the vascular system generally seems to be overfall, though the excess is most marked in the arterial system, Arteriotomy, however, is seldom called for, though it might at first sight seem indicated, since venesection usually answers every pur- pose. In asthenic plet)iora, on the other hand, the venous system only is overfilled ; the right side of the heart is distended and its action is laboured. Here venesection is sometimes called for, but it should be carefully employed. It is seldom necessary to withdraw more than 6 to 10 ounces of blood, and often a smaller quantity suffices. Peritonitis. — The relief obtained by bleeding in acute peritonitis rendered venesection a famous remedy in this affection in former times. And there can be no doubt about its efficacyin relieving the pain of peritonitis, as of inflammation of other serous membranes. It may be used when the patient is young and strong, and in that stage of the disease which is accompanied by a small, hard, and wiry pulse — the pulse of a contracted artery, of augmented tension from contraci^ion, not from overfulness. It is worse than useless in the later stages of the disease, when adynamia has set in. But valuable as bleeding may be in certain cases of peritonitis, it rarely happens that it is admissible, for in the great majority of cases inflammation of the peritoneum is second- ary to other diseases, and notably to disease of the kidneys. Where peritonitis arises after delivery it is commonly of septicsemio origin, and it is seldom indeed that bleeding is of any avail under these conditions. So that, practically, bleeding is not a remedy, which we can often employ in peritonitis. A very high temperature cannot alone be held to be indicative of its use, for it so happens that such pyrexia is as a rule present only in septicsemic cases. Some cases of peritonitis, even fatal ones, run their course without any marked elevation of temperature : or indeed without showing any definite symp- toms. Probably venesection is most serviceable in traumatic peritonitis, or it may be, when the inflamnfation is localised, though in that case leeches are more suitable. Pleurisy. — ^Wben pleurisy attacks a young and rpbiOst patient, and is accompanied by severe pain, great relief follows blood-letting. The blood should be taken from a vein, and pleTio rivo. But when, as so often happens, pleurisy is, like peritonitis, secondary to damaged blood-con- ditions— e.^. Bright's disease— bleeding is often inadmissible. When, as in pleuro-pneumonic cases, pleurisy complicates pneumonia, bleeding may possibly be called for, if there be great pain and oppression of the chest ; but it should be most eiicuiuspeotly weed. Local blood-letting is much to be preferred if bleeding be thought necessary ; for general blee4ing is usually incompatible with the strength of the patient. _ , Uremio Asthma. — In the affection known as ursemio asthma, in which there is spasm of the systemic arterioles, with intense turgidity of the arterial system and engorgement of the left heart, bleeding, in the form of arteriotomy, appears to be clearly indicated. Spasmodic Bronchial Asthma. — Pure asthma is doubtless often a nervous malady, and blej^ding is not a remedy which should ordinarily be employed for its relief. It is only admissible when spasm of the pulmonary vessels,, or obstruction to the flow of blood through them from bronchiole-spasm, leads to rapid engorge- ment of the right heart and venous system. This is the exact converse of ursemic asthma : but the effect in both is impediment to the aeration of the blood. Here the abstraction of a few ounces of blood from a vein may give immense and very prompt relief. , , Emphysema. — It is not so, however, in; the so-called ' asthmatic attacks,' which chronically ejn,physematous pe,ople are so prone to. Here venesection may be imperatively demanded when an acute attack of bronchitis has, by adding to the already difficult passage of blood through the lungs, excited rapid engorgement lOf the dilated heart and previously turgid venous system. Puerperal Diseases. — Formerly bleeding was much employed in midwifery practice, and espe- cially in inflammatory affections after delivery. We now recognise that for the most part post- partum affections arise from septic mischief and are of an adynamic type. It is but seldom that we are called upon to bleed in these cases. Nevertheless, now and again, venesection may be called for. Disorders of Menstruation. — ^Bleeding is a most valuable remedy in certain menstrual disorders, and especially in the pletiora of women at the change of life. Many women suffer distressingly from general vascular disturbance at this period. The flushings, headaches, giddiness, feeling of oppression and other vaso-motor phenomena which they suffer froRi in association with the cessation of, the catamenial flow, are immensely relieved by an occasional venesection. No other measure will so quickly and so effectually relieve these symptoms. Some robust, plethoric, amenor- rhoeic young women require periodical bleeding. The writer has known the abstraction of a few ounces of blood to be speedily followed by the occurrence of the menses, in cases of what may be called congestive amenorrhoea of many months' or even years' duration. It may be well to state in this connexion thatin certain pulmonary, intra cranial, and other visceral lesions, danger may arise from the augmented arterial tension which for a few days precedes the flow, and that the abstraction of blood may avert hsemorrhige into the damaged organs. After Operations.— Bleeding is less frequently e^edforin surgical than in medical practice. It IS indicated mainly in the after-treatment of oases which present engorgement of the ,right heart and venous system, as in some cases of ovario- tomy and other operations involving the db- BLOOD. ABSTRACTION OF. dominal or thoracic caritiea. A turgid venous system, vitli a small hard pulse, and a labouring heart — a condition which isOftenassociatedwith scantiness, amounting almost to suppression, of urine— indicates blood-letting after Operations of tlie kind above referred to. Shock. — In certain cases of shock the abstrac- tion of a limited amount of blood may be required. This point will be found discussed elsewhere {see Shock). Fever. — That bleeding will lower the tempera- ture of fevered patients has been known from the earliest times. It is, however, not a remedy to be resorted to for that purpose alone, for, as the most pronounced hyperpyrexia occurs chiefly In association with conditions leading to great depression, blood-letting is under such circum- stances as useless as it is dangerous. Insolation. — There are few disorders in which blood-letting is more successful, when rightly employed, than in sunstroke. It is seldom necessary to take more than a few ounces of blood ; and excess should be particularly guarded against, for fear of subsequent collapse. The insensible patient with turgid veins, a tight pulse, and labouring heart, will gain immense and prompt relief from venesection. The ex- treme pulmonary tiongestion and over-distension of the right heart so often found post mortem might ' probably be prevented by the timely abstraction of a little blood from the venous system. Bleeding is not to bo thought of in the syncopal form. 3. Methods of Bleeding. — The following are the methods of performing the Operations of arteriotomy and phlebotomy. Art^riotdnii/: — This operation is best per- formed on the temporal artery. The vessel should be pai:tially cut through by a simple transverse incision, and when a sufici'ent quan- tity of blood has been obtained it may then be completely severed, so that, retraction of both ends taking place, the hsemorrhage may be arrested. A compress of dry lint should then be applied, and a tight roller-bandage applied over it. Venesection. — The median basilic vein is the one usually selected for the operation on account of its being most readily found. The brachial artery lies immediately beneath it, and care must be taken to avoid wounding the latter vessel. The median cephalic vein is preferable, but is not so easily found; A vein on the dorsum of the foot or other part of the body may be chosen, but, as a rule, it is not desirable to open the jugular vein, especially on account of the danger of the entrance of air, and other risks. The steps in the operation on the arm are as follows :— First, the limb is to be firmly bound above the elbow b/ a broad tape or fillet. This should be applied with sufficient tightness to compress, and preveut the return of blood by, the veins, but not so as to intercept the current in the artery, and extinguish the pulse. An oblique slit is to be made' in the vessel by means of a small lancet, care being taken not to cut too deeply. The spirting blood shoiJd be caught in a vessel rtnd measured. Whisn sufficient blood has been withdrawn, the operator should finSily place a thumb or a finger lis on the aperture, and then, on removing compres- sion, place upon the wound a dossil of dry lint^ antiseptic dressing, styptic-colloid, or such-like, over which a roller-bandage should be twined a few times like a figure of 8, the cross being over the wound. Local bleeding.— The object of local bleeding is the relief of congested vessels, and especially those of inflamed parts. Arteries convey more blood to, and veins convey more away from, in- flamed parts ; so that local bleeding may give great relief and initiate resolution, since ab- sorption does not fully commence until inflam- mation has ceased. Methods op Local Bleeding. — Blood may be abstracted topically by leeches, by scari- fications, or by wet-cupping. 1. Leeching. An average leech will abstract nearly half an ounce of blood. Leeches are extremely useful in a great variety of affections, since a pretty definite amount of blood can be withdrawn from the affected or adjacent parts, or from more distant parts, through intimacy of the vascular connexion, as in diseases of the eye and ear, and in hepatic diseases, accom- panied by obstruction to the flow of blood through the portal system, when the application of leeches to the anus is most valuable. Care should be taken not to apply leeches to parts over which sufficient compression cannot be made to control the bleeding, should any difficulty arise in arresting it otherwise. Thus, leeches should hot be applied over the trachea, especially in children, in whom the error of applying them over the epistemal notch is some- times made. For the same reason the fonta- nelles should be avoided. The skin of the part where leeches are to be applied should first be washed, and when they do hot bite readily the part may be wetted by a little milk or sugar and milk. A slight prick of a needle, sufficient to draw a speck of blood, will often cause them to bite when re- fractory; Should the bleeding continue too long after the leeches fall ofi', pressure or styptics may be applied. If it is desired to encourage bleeding, fomentations of hot water or linseed poultice are serviceable. In applying leeches to the cervix uteri the precaution of closing the os by a plug of wool, should not be neglected. When applied within the mouth a leech-glass should be used. 2. Scarifying. — Scarifications consist in small cuts of a depth hot exceeding the eighth of an inch or less into the tissue whence it is desired to take blood. This mode of topical bleeding is mainly applied to the cervix uteri, to the tongile in acute glossitis, and to the palpebral conjunctiva in certain kinds of conjunctivitis ; in the last case only slight incisions are permis- sible. Deeper punctures are made by some prac- titioners into the tissue of the' oen'ix uteri, but these are punctures and not mere scarifi- cations. 3. Cwp^Jn?.— Cupping and the use of the scari- ficator constituting wet-cupping is an important method of topical blood-abstraction ; and as a considerable amount of blood can thus be with drawn, the general circulation may thereby be lie BhOOV, AiSSTllAUXiun un. affected. It is ordinarily employed, ho-vrerer, for its local effects. The method of its performance is as follows:— Cupping-glasses being first put on for a brief time, as for dry-cupping (see Cdppinq — Bri/- Cupping), the operator applies to the part selected a spring scarificator so adjusted as to cut only to the required depth; — about an eighth of an inch or less. The cupping-glasses are then re-applied, and the desired number of ounces of blood abstracted. If the glasses be too tightly attached the blood -will not flow readily, and un- necessary pain may be caused. After their re- moval adhesive plaster or dry lint and a bandage should be applied to the part. Cupping over the loins is extremely useful in renal ischaemia ; on the temple or behind the ears in certain cerebral disorders; down the spinal column in inflammation of the spinal cord or meninges ; and on the chest in certain pulmonary affections. Aifbbd Wiltshire. BLOOD - DISEASE. — The term blood- disease was used by the humoral pathologists as synonymous with dyscrasis or anomalous crasis of tlie blood, and expressed the idea that the blood was the seat ' almost without exception ' of all general diseases. And, further, since purely local disease was considered to be ex- ceptional, the vast majority of diseases were referred to dyscrases, and were classed under the head of blood-diseases. The condition of the blood was considered by the humoralists to depend upon the crasis, that is the mixture, of its constituents; and promi- nent among its constituents were reckoned the blasteTimta, or germinal substances of the differ- ent tissues, which exuded through the capillary walls in the process of nutrition. When the blood-crasis was disordered or diseased, a dys- crasis was said to exist, and dyscrases were held to be in the majority of cases primary ; though it was allowed that local anomalies of nutrition might and did occasionally occur, and give rise to secondary dyscrases. A blood-disease or dyscrasis being established, all morbid changes throughout the body wero believed to be but local manifestations of the same. For the pur- pose, therefore, of a rational classification of diseases, a previousclassification had to be made of the dyscrases. The principal blood-erases were said to be :— 1. The fibrin-ee&siB; including the simple fibrin-crasis, the cfoupoua crasis, and the tubercle- crasis as varieties. The local expression of the fibrin erases was inflammation in some form. 2. The venous crasis, in which fibrin was deficient. This iocluded a vast number of special erases, lying at the foundation of the most diverse diseases— e.j'., plethora, heart- disease, acute exanthemata, rickets, albuminous urine, cholera, acute tuberculosis, lardaceous disease, cancer, acute convulsive diseases, me- tallic poisoning, &c. 3. The seroKS crasis ; associated with aniemia. i. The putrid or septic crasia. 5. Anomalous erases; such as those of syphilis, gout, &c. The theory of dyscrases may be said to have dooliuod since the appearance of Virchow's ^U\J\JXJ, ^U.VyXbJ.'^ Cellular Pathology. Virchow showed that the blopd is in every relation a dependent and not an independent fluid, and that the sources from which it is sustained and restored, and the ex- citing causes of the changes that it may suffer, He without it and not within it. Substances may enter the blood and affect the corpuscles in- juriously ; the blood may act as a medium in conveying to the organs noxious substances that have reached it from various sources; or its elements may be imperfectly restored. But never is any affection of the blood itself — any 'dyscrasis' — pennanent, unless new influences arise .and act upon the blood through some channel or through some organ. At the present time, while it cannot be said that humoralism is professed by many patholo- gists, the notion of blood-disease, as generally entertained thirty years ago, still clings to thti nomenclature, and pervades some of our patho- logical doctrines. Diseases that affect the whole economy — syphilis, tuberculosis, gout.and cancer — are frequently described as 'constitutional,' or ' blood-diseases,' and that whether theil general manifestations are secondary to local disease, as in syphilis and cancer, or are refer- able to inheritance. While the morbid conditioni of the blood are real and numerous, 'blood- diseases,' so called, are but abstractions, and, as such, a fruitful source of confusion and useless discussion. It is desirable that the term blood- disease should be abandoned, and that the ex- pression morbid conditions of the blood should be applied to the pathological states of the vital fluid, which can be distinctly demonstrated by physical, chemical, or histological examination. J. Mitchell Bruce. BIiOOD, Illprbid Conditions of. — The characters, composition, and functions of the blood in health are sufficiently familiar, and do not require to be described here. But certain facts connected with the physiology of this fluid have a special bearing upon its pathology, and must be briefly considered before its morbid states can be profitably discussed. A. Physiology of the Blood. — The Red Cor- puscles of the blood consist of two portions— a colourless, sponge-like matrix ; and a coloured sub- stance of complex composition, which occupies the interstices of the former and accurately fills them. The matrix is regarded as possessing chiefly physical properties ; while its contents constitute the active part of tie corpuscle, . and consist of haemoglobin. The source of the red corpuscles is of the greatest pathological importance. In the embryo the blood and blood-vessels are deveioped from the same elements, and thus the two struc- tures in their physiological aspect are essentially inseparable. In fully-developed blood the source of the red corpuscle is obscure: but there can be no reasonable doubt that, it originates in the colourless corpuscle, and more remotely in the lymphatic glands, the spleen, and the medulla of bones; and that light is of the greatest importance in the formation of hsemogior bin. With respect to the properties and fvinction of the red corpuscle, it is to be noted th^t the ultimate elements of haemoglobin are carbon, nitrogen, hydrogen, oxygen, sulphur, and iiou, BLGOD, MOBBID CONDITIONS OF. 117 —the last of these probably being the cause of its red colour. Hffimoglobin is soluble in water, forming a lake liquid from which fine crystal's may be obtained, and which may be variously decomposed, giving rise to other ' blood crystals.' Most important of all its properties, hsemoglobin combines with certain gases to form definite chemical compounds; — with to form oxyhsemoglobin ; with CO to form carbonic- oxide-hiemoglobin ; and with N "0 to form nitrous- oxide-hsemoglobiu. These compounds, and es- pecially the oxyhsemoglobin, are exceedingly unstable, being reduced even under very feeble influences to haemoglobin and their other con- stituents respectively. Alternate oxidation of hsemoglobin and deoxidation of oxyhsemoglobin are constantly going on within the red corpuscles of the circulating blood ; and the two changes, occurring in the pulmonary and systemic capil- laries respectively, constitute the first great func- tion of the blood — its oxygenating or respiratory function. The volume of oxygen in arterial blood is 16"9 per cent, and in venous blood 5'96 per sent. It must be clearly understood that dis- orders connected with the red corpuscles or respiratory elements of the body, -whether in amount, composition, or circulation, directly k.ifect the oxidation-processes only. Besides its origin and its function, there is a third relation of the red corpuscle to the organism — namely that of it^ prodmis. These are eliminated by the ordinary channels ; the salts, which are chiefly salts of potash, being excreted by the kidneys, and the coloured material furnishing the pigments of the bile and urine. The fVkiie or Colourless Corpuscles of the blood, also called Leucocytes, are chiefly derived from the corpuscles of the lymph, and the cells of the lymphatic glands and allied organs, which they closely resemble. By escaping through the walls of the blood-vessels, they become identical with the wandering-cells of tissues and with pus-corpiiscles, — from which they are indistin- guishable except by locality. Such is the Origin, and such are some of the functions of the white corpuscle, and its_ occasional development into the red corpuscle has been already mentioned. It might, therefore, be expected that morbid states cf the leucocytes would be associated with dis- order of the lymphatic structures and connec- tive tissues, of the red corpuscles, and of the blood-vessels, and this will presently be shown to be the CMse. The proportion of white corpuscles in the blood is subject to physiological increase, without becoming excessive, as after meals, dur- ing periods of growth and development, and in menstruation and pregnancy. This state is called Physiological Leucocytosis (Virchow), and signifies' lymph-glandular excitement. Plasma.— 'Shu physiological relations of the plasma to the organism are extremely complex ; and disturbance of these relations furnishes many of the symptoms of disorder of the blood. Its raaXrati Junction is essentially one of nutrition — it supplies the tissues with oxidisable material for development, growth, support, secretion, and the liberation of force. The source of the plasma is equally extensive. It derives its principal con- stituents from the alimentary canal thtoiigh the absorbent glands and liver ; while other impor- tant albuminous substances are being eonstarltly supplied from the tissues generally, through the lymphatic system. Lastly, the •products of the plasma, such as carbonic acid, urea, and water, are discharged by the regular excretory channels. Thus the condition of the plasma is found to be most intimately associated with that of the or- gans and tissues generally, whether as regards its origin, its mature function, or its products ; and it will therefore be affected by disorder or disease of every organ, whether alimentary, sanguifacient, or excretory, and of all the tis- sues. Coagulation of the Blood: Fibrin, — Under certain circumstances, especially after removal from the body, the blood coagulates, and fibrift separates more or less completely from the other constiituents. This change is now believed to be due to the action of three bodies contained in the plasma — two fibrin-generators, named respec- tively fibrinogen and fibrinoplastic substance, albuminous in nature; and the third a ferment. The anumnt of fibrin produced varies not only with the amount of these bodies, but with the amount of salts, with the degree of alkalinity and of heat, and with other influences ; and these variations are subject to no law at present known. The rapidity of the process depends upon (1) the amount of ferment; (2) its in- creased activity by agitation of the blood and by elevation of temperature ; and (3) the increased number of points of fcontact (so- called ' catalytic ' action) by the presence of red corpuscles, hsemoglobin, charcoal, &c. It thus appears that the expressions ' amount of fibrin ' and ' rapidity of coagulation,' however important as facts, do not afford any definite indication of the state of the blood; as has been generally believed hitherto. Tiiree essential factors, and a large number of accidental influ- ences, share in the process ; theymay do so in very various proportions and degrees ; they do not vary together ; the amount of flbrin is not in proportion to any one of them ; and after coagu- latibn is complete, portions of all the factors probably remain nneombined. The part played by the red corpuscles in coagnlatiou is' a double one^l) the corpuscles, as ' points of contact,' greatly increase the rapidity of coagulation ; and (2)' they supply oxygen, which appears to be indispensable to the process. The leucocytes probably produce the ferment. B. Pathology or the Bioon. — The morbid states of the blood will now be considered in the following order: — 1. Changes in quantity, and the effects of such changes upon the composition of the vital fluid. 2. Morbid conditions of the red corpuscles. 3. Changes in colour, i. Melansemia. 5. Morbid states of the ■ white corpuscles. 6. The pathology of the blood-plasma ; and of the process of coagulation. 7. The presence of foreign materials in the blood, including poi- sons and infective substances. 8. Organisms. 1. Changes in Quantity of the Blood. — Alterations in the total amount of blood in the body are perhaps never simple, but always as- sociated with alterations in quality. a. Polyhemia, or excess of blood in the body generally, may be the result either of excessive ingestion of the elements of blood; of the accu- 118 BLOOD, MOEBID mnlation of the same by the suppression of habitual haemorrhages or fluxes ; of the loss or obsoleteness of a part of the body, such as a limb or a lung ; or of insufficient exercise. It cannot be said, however, that polyhsemia has ever been demonstrated by exact ■ investigation, inasmuch as the total amount of blood in the body is still uncertain, and . the physiological limits in this respect are very wide. jPolyhsemia is believed to be present in plethora, along -with relative excess of, the solids, and especially of the red corpuscles (see Plbthoba). A. Oligemia or deficiency of the total amountof blood is, on the contrary, an exceedingly frequent change, and constitutes the simplest form of atuemia. It is, however, probably never pure, inasmuch as alterations in quality appear to be inseparably associated with it ; and the terms hydramia and spaniBmia have accordingly been used as synonymous with the preceding. The manner in which diminution in quantity gives rise to alteration in quality must be considered here. When haemorrhage occurs to any amount, and the whole quantity of blood in the vessels is re- duced, the pressure falls, and absorption of the parenchymatous plasma rapidly follows; by which, along with vaso-motor stimulation, the physical relations are restored. If the loss of blood has been moderate, the only change: in its composition may be considered to, be oligoey^ thtsmia, or diminution of the red corpuscles, which alone of all the constitnents of the blood cannot be rapidly restored. If the haemorrhage has been more serious, the fluid absorbed, into the circulation from the tissues, from the sup- pressed secretions, and from the alimentary canal, consists of water in ever-inpreasing excess, which carries with it an amount of salts equal to one- niQth the loss in albuminous substances. The morbid state of the blood is now beyond oligocy- thaemia; there is deficiency of albuminous con- stituents, or hypalbuminoaie, and the condition correctly called muBmia is the result. The total quantity of blood probably remains for some time below the normal. A similar impairment of the quantity, and therewith of the quality of the blood, may be. slowly developed by repeated small haemorrhages, or by any cause whatever that impoverishes the blood, whether of the nature of waste or of want. The condition which results closely resembles that just described in the acute form — oligsemia with oligocythaemia and hypal- buminosis : the same is known clinically as anamia, {see Anemia). As a therapeutic measure qljgaemia may be desirable. It may be induced either (1) by direct abstraction of blood, or (2) by gradual impoverishment of the blood, and reduction of the intra-vascular pressure. 2. Morbid Conditions of the Bed Corpus- cles. — The pathology, of the red corpuscles is still imperfectly understood. The fpUowing comprise the most important changes connected with them so far as they are known. a. Polycyihamia. — Increase in number of the red corpuscles is never considerable, being generally transitory and within physiological limits; for example, in the newly-born, and after Eieals. It has already been mentioned as associated CONDITIONS OP. with polyhaemia in plethora. In the algid stage of cholera the red corpuscles are relatively in excess b. 0%oeyM«»J«a.— Diminution in .number of the red corpuscles is, on the contrary, of very frequent occurrence, and of the greatest patho- logical importance. Microscopically the, num- ber of red corpuscles, in a given visible area of blood is diminished ; and chemically the amount of haemoglobin in a given volume of blood may fall from 1 5 even as low as 5 per cent. The principal circumstances trndei which oligocy- thaemia occurs are — ( 1 ) in anaemia, or diminution in the amount of blood as a whole, from any cause, whether rapid or protracted, especially as the result of fever ; the red corpuscles suffer, ing early, seriously, and persistently, as com- pared with the other constituents-: (2) in leucocythaemia — the development of the .red corpuscles being interrupted : (3) in hypalbumi- nosis, where the red corpuscles like other elements suffer from want of albuminous material : and (4J in chlorosis. See HiEMAcyTOMETEB. c. Oligochronucmia.^-DeSciency of the red cor- puscles in haemoglobin has been described by this name, and is a morbid condition of the greatest possible interest, inasmuch as it is one of the essential alterations of the blood in chlorosis. When the individual red corpusde contains less haemoglobin than normal, it is said to present a pale appearance to the eye. A more trustfrortiy method, of determining the richness of the red corpuscles in hsemoglobin, is by means of the haemoglobinometer(«ee H.EMOGiOBiNOMETBK). Or we may compare the amount of haemoglobin in a given weight of blood with the number of red cor- puscles in a given microscopical area. When the former is small in proportion to the latter, the defect must lie in the individual corpuscle ; and this may be so great that the proportion of hae- moglobin falls, as in some cases of chlorosis, to 2S per cent, of the normal. See Chlorosis. a. Aglobulism.-^The effects of the two con- ditions of blood just described, namely, oligocy- thaemia and oligochromaemia, may be discussed together under the head of aglobulism, or defi- ciency of the blood in haemoglobin. Want of the oxygenating substance of the organism gives rise to symptoms at once extremely various, and of the most serious import. Every vital prcess, whether developmental, plastic, secretory,, dyna- mic, or nutritive, is. absolutely dependent on a &ee and immediate supply of oxygen. All of these processes, therefore, wUl suffej; in aglobulism. The respiratory and circulatory, movements are accelerated. The complex processes of -alimen- tation and secretion are performed imperfectly, and the, results are dyspepsia,- constipation, and disordered sanguification — which intensify the abnormal blopd-state. Muscular contraction is feeble, and csfnnot be sustained. .Psy- chical, force is weak; and dulness, sleepiness, pains, and other symptoms indicate imperfect oxidation, within the nervous system. .Bodily growth and developnieijt-T!-as of the sexual organs, for example — remain incpmplete. and puberty is deferred. ^Nutrition everywhere suffers, the ma- terials being insufficiently oxidised; and sub- stances 'intermediate' to albumen on the one hand, and carboiiic acid, water, and urea on BLOOD, MORBID CONDITIONS OF. the other hand, are formed, especially oils. Thus the organs and the connective tissues become loaded with fat and enlarged, instead of suffering atrophy, as they do Trhen the blood- plasma is deficient. ■ Finally the excretions are disturbed, and the subject of aglobulism presents derangement of the colouring matters of the bile and urine, which are derived from haemoglobin. Histological changes. — Alterations in the BUie, outline, axii Consistence of the red corpuscle hare been frequently recorded, but such accounts are incomplete, and no successful attempt has yet been made to connect any of these changes with morbid processes in the tissues. In severe fevers, such as typhus, and in some rapid malig- nant diseases, the red corpuscles appear pecu- liarly soft, their outline being less resistant and sharp, and the bodies running together into ir- regular heaps, instead of into roK/ea«ir with well- defined lines of contact between the elements. In another class of cases the corpuscles appear small and crenated or like the ' thorn-apple.' Maerocy- thamia and Microcythtemia hare also been de- scnbed as temporary and variable conditions, in which the red corpuscles are abnormally large and abnormally small respectively. Transitional cells between the white and the red corpuscle are unusually numerous in some cases of leuksemia. 3. Changos in Colour.^ — The colour of the blood is chiefly due to the red corpuscles, and alterations from the normal in this direction will be best considered in this place, although the white corpuscles and the plasma may also affect the colour, as will be presently shown. mId and hydraemia — allowing more rapid sinking; (2) interference with the catalytic action of the haemoglobin, which is so powerful in determin- ing the rapidity of coagulation, as in fevers and oligocythaemia; and (3) want of oyx^en, corre- sponding to the amount and condition of the hsemoglobin, as in the same diseases. One and all of these states render the process of coagulation slow compared with the descent of the red cor- puscles ; and the buffy coat is the result. It thus appears that the buffy coat is no indication whatever of excess of fibrin-generators, or of the opposite; and that it is found under the most diverse conditions of blood, (4) Salts. — The amount of positive knowledge concerning morbid alterations of the salts of the blood is but small. It is to be observed that the salts of the plasma have chiefly sodium as their base, while potassium-salts mostly reside in the corpuscles. a. Diminution. — In febrile diseases there is an increased discharge of compounds of both bases, but at different periods; the potassium-salts ap- pearing in excess in the excretions until the crisis IS past, and the sodium-salts during defervescence. At both periods, it may be considered certain that the blood is the chief source of the salts ex- creted; and that it is accordingly deficient in these constituents. b. Excess. — On the other hand, the salts of the plasma are relatively in excess in hypalbumi- nosis, replacing, in the proportion already stated, the lost albumen. The effect on the salts of the blood of such drains as occur in cholera has been variously stated; some authorities declaring that it is an increase, others a diminution. c. Eeaction. — The alkalinity of the blood is said to be diminished in gout, cholera, and osteo- malachia. (5) Fats. — ^The normal iiicrease of fats in the plasma that occurs after meals may be exaggerated by a diet rich in oil, and, it is said, in chronic drunkards and in persons disposed to obesity. When this increase is so great that the serum presents a milky appearance the blood has been called chylous. A cream-like scum forms on the surface of the serum ; and- the milky appear- ance is found microscopically to be due to the presence of fine granules and oil-globules. A marked increase of fatty matters in the blood has been found in some cases of cbyluria. Fat may also appear in the blood as a foreign body, by the escape of marrow into the circulation in fracture of bones — and that in such quantity as to cause fatal capillary embolism. (6) CAnnoNic Acid, which exists in arterial blood in the proportion of .30 per cent., and in venous blood of 36 per cent., by volume, may accu- mulate, within the circulation either by increased formation or by retention. Although associated with asphyxia, this increase of carbonic acid is 122 BLOOD, MOEBID CONDITIONS OB. probably not the cause either of the symptoms of that condition, or of the dark coloui of the blood that accompanies it. ' (7) Othee Constitdhnts. — Amongst the most important of the other constituents of the bloody the following are to be noticed : — a. Urea, which exists in normal blood to the amount of 1-8 parts in 10,000, may increase in uraemia by two or three times. . There is still much uncertainty, however, on this subject {see Urjemia). Disease of the urinary organs, which interferes with the elimination of urea and allied products from the blood, is the usual cause of ursemia; but excessive tissue-change, as in fever and inordinate muscular exercise, has also the same eiFect. b. Uric acid, found in normal blood in minute traces, is increased (as urate of soda) in all cases of gout, and may amount, according to Dr. Garrod, even to 0-176 parts in 10,000. Its presence is easily demonstrated by the thread-experiment {see Gout). Uric acid is also increased in leulcse- mia and chlorosis — probably from the imperfect oxidation associated ^ith the condition of- the red corpuscles. c. Imei/n, tyrosin, hippwria acid, sarcin, and other allied complex compounds, have been fre- quently found in the blood in small quantities, and tlie same may be said of oxalic and lactic adds, and of acetone. d. Bile. — Certain of the constituents of the bile mayoccurin theplasma. Themostobviousof these are the bile-jpigments^—biliniMn and bilivcrdin, which either by direct formation in the blood from the haemoglobin, or more frequently by absorption from the liverj accumulate within the circulation, and by their deposit give rise to the colour of the tissues in jaundice. The bile-adds — glycocholic and taurooholic acids — are also under certain cir- cumstances absorbed into the blood, where they may be detected with difficulty. They have a destructive effect upon the red corpuscles, and act fuKher as a powerful poison to the tissues, causing the excessively severe symptoms that may occur in hepatogenous jaundice. Cholesterin is credited by some pathologists with being the cause of the same symptoms, and it has been found in the blood in increased proportion in some cases of severe jaundice. e. Sugar. — The sugar of the blood is increased in diabetes, in some cases reaching 0-3 to 0"5 per cent. 7. Extraneous Matters in theBlood. — Be- sides its normal constituents and their products, the blood mayoccasionally contain certain matters entirely foreign to it such as the numerous poisons which act either directly upon the corpuscles, or remotely upon the organism. These, entering the circulation before they exert their specific effect, are in many instances readily discovered by analysis. The acid compounds of hydrogen with sulphur, phosphorus, arsenic, and antimony, respectively, act as blood-poisons by depriving the oxy haemoglobin of its oxygen ; while carbonic oxide and nitrous oxide unite with the haemo- globin, and expel the oxygen from the blood. It is a matter of speculation whether other so- called poisons, the nature of which is still obscure, do_ not enter the blood and there exert their primary effect, such as the contagium of acute BOILS. specific fevers and other infectious disorders. Similar infective matters, produced in the' tissues of the body itself, are believed to be absorbed in septicaemia, pyaemia, and other allieddiseases, and numerous observations support the farther be- lief that the presence of bacteria is intimately associated therewith. A somewhat similar in- fection may occur in malignant disease, the juices being mixed with the blood-plasma, but in some instances the process may be different, namely by means of cells. We cannot expect to detect these cells in the blood in transitu. The same remark applies to embola, of whatever nature, and to blood-crystals. 8. Organisms. — The blood may contain a variety of living organisms, either foreign or peculiar to itself ; the latter being called homo- tozoa. See Smuatozoa, Chylubia, and Ke- lAPsiNO Fevek; also Bactebia, Filabia San- GuiNis-HOMiNis, MicBococci, 'SPiBULUM, and ZyME, J, XlTCHBLL BbUCB. BLOOD, Transfusion of. See Tbansfcsion. BLOOD-'WOHMS. — This term is of general application. It refers to all kinds of Entozoa living in the blood. See Hsematozoa. BLXTB BISIjASE. A condition in which the most prominent symptom is a peculiar disco- louration of the skin and mucous membranes, due to the circulation of dark blood in the vessels, jS'ee Cyanosis; and Heabt, Malformations of. BOIIiS. — Synon. : I'nruneles ; Fr. Furoncle; Ger. Furuniel. , Definition. — Gangrenous inflammation of the skin, forming small painful swellings, and ending by expulsion of the necrosed centre, or ' core.' The inflammation begins in the gl?.iidu- lar structures, hence involving not only the skin, but also the cellular tissue immediately beneath. The sebaceous glands are most commonly the seat of boilsj but occasionally the Meibomian glands {stye), the ceruminous glands, and the sweat-glands of the armpit; or, more rarely still, the glands of the lips, vulva, or anus are affected. .Etiology.^ The predisposing causes of boils are : — the male sex ; middle life ; a stout habit of body ; seasons of spring and autumn ; a diet too full of flesh, or one suddenly changed, such as that adopted during training for rowing, &c. To these must be added the vitiation of the blood during exhausting fevers and in certain cases of saccharine urine, or induced by inhaling dissecting-room effluvia ; and dirty occupa,tipns, for example, chimney-sweeping or rag-picking. Lastly, boils are sometimes epidemic. Local causes. — The parts of the skin most ex- posed to dirt or chaflng, the hands and face, the neck and back, the buttocks and knees, are favour- ite sites for boils ; bntthey may form on any part except the palms and soles. Blisters, poultices, and stimulating liniments occasionally cause them. To these causes is added by some authprs the specific contagion of a parasitic fungoi4 plaAt, the mycelium of which, by developing jn. a gland- cell, thereby causes limited necrosis (the slough) of the tissue in which it grows.. The truth of this view is not yet clearly established, Symptoms. — Boils appear either singly, in succession, or several at once, forming (hen an BOIM. lSi8 emption on the skin. The solitary toil begins with itnhuig ; soon a reddish pimple forms, sometimes tipped with a minute vesicle, in the centre of which a hair may generally be detected. The pimple grows larger and harder, the red area in- creases and grows darker, and pain begins, sting- ing at flist, then throbbing. In about flvedays the summit breaks, pus oozes forth, the pain abates, and the hardness diminishes. A day or two later the coru, a shred of sphacelated cellular tissue, escapes. Tha boil then subsides, and healing rapidly takes place ; the scar is depressed, and for some time of a violet colour. Occasionally the inflammation affects chiefly the cellular tissue beneath the skin ; the mass is then softer, more round and clearly circumscribed, and fluctuates like an abscess — this variety forms in the arm- pit. Earely, the central slough extends rapidly beneath the surface, and communicates with the surface by several small apertures (carbimale). In other cases the swelling is more difTuse; no core appears at tha surface, but a hard very painful pimple is formed, which is long in sub- siding (blind boil). The furuncular eruption, consisting of groups of small boils, forms suc- cessive crops, and thus the disease may continue a long time. Soils are generally limited to a small region, but this is not always the case ; and the greater part, even the whole, of the body may be attacked. The constitutional disturbance is usually nil or slight when the boil is due to local irritation, though it may suffice to render nervous, irritable persons unfit for work. When the boils are caused by exhaustion, the general symptoms are severe and denote great depression. Prostration, agitation, stupor, low delirium, dry brown tongue, sordes, vomiting, and diarrhoea set in, and the ease often ends fatally; or recovery is very slow, accompanied by much suppuration. i Septic ab- sorption and pysemia very rarely take place. Carbuncular Boil of the Face. — There is a rare and often fatal form of boil, the determining cause of which is unknown. It is met with only on the head and neck, notably on the lip. Mild and trifling at first,, like an ordinary boil, it rapidly extends by infiammation of the veins or lymphatics, and causes poisoning of the blood. The earliest sign of this fatal change is the occur- rence of violent and repeated shivers. The boil becomes a boggy swelling of blackish violet colour; the surrounding tissues become hard and brawny; suppuration ceases; sloughing occurs ; the complexion grows earthy ; the fea- tures, if the boil is on the face, become everted; the skin round the eyes in some cafes is puffed out, and the eyes themselves project from the sockets ; anxiety and laboured gasping breathing set in; and a violent constricting pain in the head, chest, or belly is frequently experienced. Delirium and coma usually supervene, but some- times conscionsness and terrible suffering re- main to the last. The duration from the first shiver to th> end is about four days. The veins of the face first inflame, and the phlebitis extends by the veins of the orbit to the sinuses in the skull, to the diploe, &c. ; hence abscesses form in the eyelid, the forehead, the meninges, or the I>ra'.n, and occasionally in distant viscera. DiioKosis. — A boil is distinguished by the central cavity and slough-^charactors peculiar to it. The boil of the face accompanied with phle- bitis has been confounded in this country with the ' malignant pustule ' Of Continentiil surgeons. The former is still a boil with a central core. The 'pustule maligne' is said to hare invariably a large vesicle surmounting a brownish eschar, with a ring of smaller vesicles round'the larger one, — a condition never met with in boils. Pbognosis. — When due to local causes, the prognosis is always good, unless the patient be exhausted by old age or fever; under such cir- cumstances the extensive sloughing and suppu- ration often lead to a fatal issue. Theatmbnt. — General. — First remove predis- posing causes, and invigorate the patient by change of air, outdoor exercise, vapour and Turkish baths. The diet should be moderate and mixed. Alcohol, unless the patient is greatly debilitated, should be given in very moderate quantity, and the form of fermented liquor most habitual to the patient is best ; much alcohol taken before the core has loosened increases the pain and throbbing. Occasionally a saline purge should be given. Of empirical remedies, yeast (a tableepoonful thrice daily) is said to put an end to the repetition of boils. Quinine and perchloride of iron are also used. Quinine should be given to an adult in flve-grain doses CA'ery six hours, till singing in the ears and head- ache begin ; it should then be gradually lowered for three or/ four days to three or four grains per diem, and then left off. In obstinate cases the waters of Vichy, Barjges, or Harrogate are believed to remove the disposition to boils. In diabetes omission of sugar-forming food, and the free administration of allcalis are the most effec- tual remedies. For the exhausting boil of th6 face, large doses of brandy, with quinine, are re- quired. Local. — When signalled by itching, a boil may be stopped by plucking out the hair of the in- flamed follicle, and in a long Buccession many boils may thus be prevented. When the areola has formed, if the pain be slight a drop of caustic solu- tion applied to the centre will sometimes check the progress of the boil. A better plan at this stage is to cover the boil with a galbannm and opium plaster (Erasmus Wilson's) spread on leather. Under this treatment pain at once ceases, the inflammation gradually subsides, and the sepa- ration of the core proceeds painlessly; when the boil discharges, a hole should be cut in the centre of the plaster, for the escape of the pro- ducts. When the pain is stinging, and the areola wide, with restlessness anit headache, warm poultices are most soothing -^ those of starch cause pustulation less than linseed meal poultices. Mixing lard with linseed poultice, or sprinkling it with the dilute solution of acetate of lead, has a similar effect. Poultices hasten the expulsioii of the slough, but should be dis- continued as soon as the hardness changes to doughiness. If the slough is large, the sur- face may be dressed with lint spread with Peru- vian balsam, and the boil carefully protected by means of pads and compresses. Incisions are now much less employed than formerly. They increase rather than lessen the loss of tissue in ordinary boils, and do not 124 BOILS, shorten the duration of the inflammation. They give relief to pain, however, and check the upread of diffused boils. When made, incisions Bhould be free, crucial, or even star-like, and carried beyond the boil. In the rapidly extend- ing boil of the face local treatment is of little avail; the free use of the actual cautery may be beneficial if employed at an early period. Berkeley Hnx. BONB, Diseases of. — Under this head are included : — Acute and Chronic Inflammation of bone and its membranes, with the consequences thereof, such as Caries, Necrosis, and Abscess ; New Growths which arise both within and upon the bone ; Malformations ; and certain Disorders of Nutrition, namely, Hypertrophy and Atrophy. Bone-tissue should be regarded as being simi- lar to other connective tissues, but some dis- eases affecting it are rendered obscure, while others are materially modified, by reason of its meshes being filled with lime-salts. 1. Inflammation. — ^As a matter of clinical convenience, it is usual to consider separately in- flammations of the periosteum, of the bone proper, and of the medulla ; but it should not be forgotten that these structures are throughout continuous and interdependent, and that disease is rarely exclusively confined to any one of them — it may originate or be chiefly developed in one, but it cannot long exist without involving the others to a greater or less degree. A. Periostitis — Inflammation of the invest- ing membrane of bone {die Knockenkaut). By periosteum is usually meant the thin fibrous en- velope of the bone in which the vessels for the supply of blood subdivide. But between it and the bone is a layer of osteogenetic cells like the cambium-layer of a growing plant, and immedi- ately external is a layer of cellular tissue, con- tinuous with that of the adjacent parts ; these are integral portions of the periosteum, and take an active share in all its diseased processes. Periostitis may be either acute or chronic. {a) Acute periostitis, osteoperiostitis, acute pe- riosteal abscess, or acute necrosis. — This is a for- midable, ' but fortunately comparatively rare, disease, at least in the adult. It attacks the long bones almost exclusively, usually those of delicate children or young adults, in whom; active bone- growth is still going on, and the periosteum is highly vascular. Acute periostitis probably never occurs without coincident inflammation of bone, and it is by far the most common cause of ne- crosis. It will be best to regard it as an acute ostitis and periostitis combined, and to call it osteoperiostitis, just as we call inflammation of the bone and of the endosteum osteomyelitis. The extent to which the hone and the perios- teum are in the first instance respectively in- volved is always di£5cult, and sometimes im- possible, to determine — it may be inferred from the extent of the necrosis. There are two ways in which the disease may begin- either in the fibrous investing sheath of the bone and the cellular layers beneath and superficial to it, from whence it spreads inwards to the cortical bone-substance, or even to the medulla ; or in the bone'tjssue — the inflammation spreading outwards to the periosteum. It is impossible BONK, DISEASES OF. in the living subject to distinguish acute osteomyelitis and osteoperiostitis arising from idiopathic causes. The disease is usually at- tributed to an injury, often slight, or to ex- posure to extremes of cold or heat. Frequently no cause is assignable. Pathology. — Rapid exudation takes place in the layers of the periosteum, and in the Haversian spaces and canals of the bone, to such an extent as to obstruct the circulation, and probably to cause by pressure the severe p.^in complained of at the outset. The exudation beneath the fibrous layer of periosteum is copious, and soon becomes purulent ; the periosteum is detached ; the vascular supply of the bone is cut off; and necrosis results. The extent of the necrosis depends upon the extent to which the periosteum is engagedi, wliilo the thickness of the dead bone depends mainly on the depth to which the inflammation in the osseous tissue extends. Large _ accumulations of pus are often rapidly formed in_ these cases, the pus escaping through openings in the fibrous envelope into the circumjacent cellular tissue. The shafts of the tibia and femur are the parts most frequently affected ; the disease occurs more rarely in the bones of the upper extremities and other parts of the skeleton. Symptoms. — One of the earliest symptoms of acute periostitis is sudden and severe pain in the affected bone, which is soon followed by intense fever. On the second or third day deep-seated swelling sets in, somewhat obscure at first. After an interval varying from five to ten days, the inflammatory signs approach the surface, the skin becomes cedematous, pits on pressure, and finally reddens and inflames. The length of interval depends on the thickness of muscles and soft parts covering the affected bone. Other things being alike in respect of pain and amount of fever, the longer the delay in the appearance of external swelling, the greater the probability that the bone is the first and chief tissue engaged, the inflammation having reached the periosteum secondarily, while the early appearance of swelling i.nd fluctuation externally suggest that the inflammation is chiefly periosteal. Blood-poisoning, either sep- ticsemic or pysemic, is a common consequence of acute inflammation of bone and periosteum. Diagnosis. — This disease may be obscure at the commencement, and its nature overlooked ; it has often been mistaken for acute rheumatism on account of the swollen joints, for phleg- monous erysipelas, for acute cellulitis, or for typhoid fever. The only malady wiih which acute periostitis need be confounded is an idiopathic inflammation of the deep-seated cellular tissue in a limb. This disease is rare. When we observe the chain of symptoms above described in a young person, we may safely assume the presence of an acute osteoperiostitis. The disease almost invariably terminates in suppuration and necrosis ; resolution happens rarely, but necrosis is not inevitable, even after suppuration. In a few cases, especially in young children, if the matter be speedily evacuated, the abscess collapses, the periosteum reunites with the bone, and no necrosis takes place. This result is unfortunately quite exceptional. Prognosis. — This must be founded on tho BONE. DISEASES OF. 125 fcxtent of the necrosis ; -whether Uood-poison- ing has taken place ; and whether the adjacent jomta are implicated in the disease. Care cannot take place until the dead bone is cast off or removed, and this is often long delayed. The usefulness of a limb may be permanently impaired by the disease, or it may require amputation, or the patient may lose his life altogether. On the other hand, the use of the limb, and the health of the patient, may become completely re- established. TEEATMENT.-r-Early and energetic treatment is of the greatest importance, as it affords the best prospect of averting the disastrous consequences of acute periostitis, but in hospital practice the cases are rarely seen sufficiently early. In the first stage the limb should be elevated, and ice applied ; painting the limb with a strong solution of iodine is advisable. As soon as the nature of the affec- tion is manifest, incisions down to the bone, so as to divide the periosteum, are indicated even before pus is formed. They relieve pain and tension,aud,by permitting the timely escape of pus as soon as it does form, the amount of perios- teal separation, and consequently of necrosis, is limited. It is the more important to make an early incision, because evidence of fluctuation is at first by no means clear or easy to make out, and tbis should, therefore, be done in all cases of doubt. Antiseptic precautions should always be taken. Sometimes the abscess-cavity does not readily collapse, owing to its walls being stiff and infiltrated, and its contents may become putrid, thus greatly increasing the patient's risks. If there be synovial effusion into a neighbouring joint, the limb should be kept at rest by means of a splint or a fixed bandage. When the acute symptoms subside, the abscess- cavity contracts, one or more simises remain, and the dead bone begins to separate {see Necrosis), Where the epiphysis is engaged in the disease the case is more urgent ; the fever runs higher, the suppuration is greater, and the degree , of joint-implication more intense, proceeding in ex- treme cases to suppurative inflammation and destruction of the articulation. The (sdema of the limb often indicates a deep-seated phlebitis, the precursor of septic poisoning. Under these circumstances, amputation of the limb is often the only resource. It is imperative to amputate where there is extensive bone-destruction, and the symptoms indicate commencing pysemia ; or where, with the death of a large portion of the shaft, one or both of the neighbouring joints has become gravely implicated, and great suffering and loss of strength forbid us to temporise. It is precisely in these eases, however, where the dinphysis has become necrosed up to the epiphy- sal junction, that good results are attainable by the immediate extraction of the dead bone. The shaft where it joins the epiphysis becomes ra- pidly detached and loose, and may easily be separated, while the bone can be divided with a chain saw beyond the limit of the necrosis in theother direction, and removed. It is diflicult, however, in the early stages to diagnose the extent of the necrosis. Where the joints both above and below are involved, amputation is DBually necessary. A periostitis cf a very acute form, almost invariably suppurating, and accompanied Irjr necrosis, is very common in the fingers, where it chiefly affects the ungual phalanges. The pain is very great, but may be relieved by an early and free incision down to the bone, which, never- theless, does not usually avert either suppuration or necrosis. (4) Chronic periostitis is usually due to some diathetic cause, but may result from injury, or from some continuous pressure. It is most fre- quent on the superficial parts of the skeleton, as the tibia, clavicle, skull, and ribs, but may affect any bone ; and it is often observed at the origin or insertion of muscles. When the disease arises from a general cause, such as syphilis, many parts of die skeleton are affected ; when from a local cause, usually only one. Symptoms. — Chronic periostitis generally takes the form of what is called a node — a tender, more or less painful, rounded or oval swelling; at fimt tense and hard, afterwards softer, or even fluctuating. The pain is much greater at the outset, from the tension of the parts involved, and is generally worse at night. Subsequently the swelling becomes in- dolent, and painless, unless pressed upon. Nodes are due to a localised inflammation. The cambi um- layer of the periosteum and its external layer proliferate and become filled with leucocytes, thus forming a well-marked projection on the bone, which may undergo resolution, suppurate, or ossify, according to circumstances. Pbognosis. — In chronic periostitis this is usu- ally favourable. Under the influence of early and suitable treatment, the inflammatory products are completely absorbed, and the bone resumes its natural shape. If the chronic inflammation of the periosteum be permitted to proceed un- checked, a deposit of new osseous lamellae usually takes place on the surface of the affected bone, giving rise to permanent thickenings, or even to osteophytio growths. These are composed of light porous bone, with a rough surface. The skeleton of a syphilitic subject will often present numerous thickenings of this nature. On making a section of the bone, it is easy to see that the new bone is superimposed upon the old, and is formed by the periosteum. Treatment When due to a local cahse, the swelling will often spontaneously subside with rest to the part, but in obstinate cases iodide of potassium internally, and iodine ointment or blistering externally, may be required. If the subject be unhealthy, or if the original injury be considerable, suppuration may take place, when the treatment will be that of an infiammaiori/ abscess. Syphilitic nodes, which are a very common expression of chronic periostitis^ yield rapidly to the influence of iodide of potassium, which in some cases may usefully be combined with a mercurial course. Blistering or friction externally is hurtful in such cases. Syphilitic nodes are not at first prone to suppuration, and even when they become soft and fiuctuating, and the skin reddens over them, they should not be mistaken for abscesses, as they readily become absorbed under suirable treatment. (c) Periostitis after iy^hM fever.— k. peculiar form of chronic perios ti tis is occasionally observed as a sequel to typhoid fever. It occurs during 126 aunis, uiBJSASJis OF. convalescence, and 'vrithovt general symptoms. It takes the form of hot, painful, and tender nodes, frequently symmetrical, and often placed on the tibia ; the disease is also found on the ribs and other bones. It may be associated with necrosis, but if so the extent of the dead bone is small-in proportion to the inflamed area of periosteum. The general health is not seriously affected, and the disease is very amenable to treatment by iodide of potassium, combined \F;th iodide of iron. £. Osteitis is an inflammation chiefly affect- ing the bone-substance ; this form may also be acute or chronic. (a) Acute osteitis is neither clinically nor patho- logically to be distinguished from acute osteo- myelitis or endostitis [see Osteomyelitis). (6) Chronic osteitis is a disease beginning in the bone, in which the chief changes from first to last occur, the periosteum being secondarily engaged. This affection may result from injury, or be ex- cited by exposure to cold ; but it often depends on constitutional predisposition, such as the syphilitic, the strumous, the gouty, or the rheu- matic diathesis, the first being the most frequent cause. It may occur in any part of the skeletop ; the chief changes, when produced by syphilis, occur in the shafts of the long bones. They con- sist mainly of hypertrophy, and the bone is ulti- mately increased in thickness, in length, and generally in density; its interior is often trans- formed into dense bone-tissue, and the medullary cavity is obliterated. Another form, associated with the strumous diathesis, is generally seated in the joint-ends of the long bones, and in the spongy bones. It is prone to end in suppura- tion, accompanied by either caries or necrosis. The gouly and rheumatic forms are associated with evidence of the presence of either of these diatheses. PiTHOLOGY. — Increased vascularity first takes place, the Haversian canals enlarge, the canali- culi disappear, the cancelli enlarge to con- tain the inflammation-products, and the earthy matter diminishes ; hence the inflamed bone softens, and, if macerated at this stage, will be found comparatively light and porous. When the inflammation affects the superflcial laminse of the bone, the periosteum becomes thick and vascular ; if the deeper parts are involved, simi- lar changes will occur in the endosteuni. The porous condition of the bone may become permanent, when the condition is called osteoporosis, the result of so-called rarefying ostitis ; or the granulations become transformed into new bone, and the cancellated structure is filled with osseous deposit, so that the whole of the inflamed area becomes very dense, and is then said to be sclerosed ; or the inflammation- process may terminate in suppuration, followed by caries, necrosis, or an abscess of the bone, which last may be either diffiised or circum- scribed. Symptoms. — These are insidious, very obscure at the outset, and may be mistaken for those of chronic rheumatism, or mere periostitis. They consist chiefly in aching, gnawi^g pain in the affected bone, with characteristic remissions and nocturnal exacerbations. The bone is tender on pressure, and feels increased in bulk at first, from the infiltration of the immediately sur- rounding soft tissues; subsequently the bone itself enlarges. There is often increase of heat in the limb. The progress is very chronic, and if unchecked by treatment may give rise to con- siderable deformity. Theatment. — ^This should be directed to the cause of the disease. If this be syphilis, an antisyphilitio treatment will be followed by good results ; even in chronic bone-inflammation, not dependent on syphilis, iodide of potas- sium is often of great service. Local counter- irritation may also be employed. Often the cause cannot be made out, and if iodide of potassium fail in producing an effect, we must fall back on general treatment. In the early subacute stage, rest, with elevation of the affected part, is very desirable. Warm fomentations, fol- lowed by iced compresses, relieve the suffering. If there be much pain and tension, leeches should be applied. Puncturing the tissues down to the inflamed bone with a tenotomy knife or flne bistoury, relieves the tense periosteum, and allows extravasation beneath it to escape, so that the pain is promptly abated. (c) Osteitis deformans.^A. peculiar form of chronic inflammation of bone has been described by Sir James Pagit under this title, from the changes it produces, both in the form and density of the affected bones. It is a chronic osteitis of the most extreme type. It begins in middle age, and may continue for an indefinite time without infiuence upon the general health, which distinguishes it clinically from other bone-inflammations. It is usually symmetrical, and affects chiefly the long bones of the lower extremity and the skull. At first the bones enlarge and soften, from excessive produc- tion of imperfectly-developed structure and in- creased blood-supply, and, yielding to the weight of the body, become curved and misshapen, but the limbs, although deformed, remain strong and fitted to support the body. In its early period, and sometimes throughout its course, the disease is attended with pains in the affected bones, which vary widely in severity, and are not especially nocturnal or periodic!. It is not at- tended by fever, nor associated with ahy consti- tutional disease. It differs from the chronic osteitis dependent on simple inflammation of bono or that produced by gout or syphilis, in affecting the whole length of the bone. Hyperostosis and osteoporosis • dependent on these latter causes rarely affect the entire bone. No treatment appears to produce any effect upon this disease. 0. Osteo-myelitis is an inflammation chiefly affecting the interior structure of the bone. Like the former, it may be acute or chronic. (a) _ Acute osteomyelitis or endostitis is a sup- purative inflammation of the medulla and bone, which verjr frequently ends in septic poisoning and necrosis. It is nearly always associated with bone-injury, and most frequently happens after amputation, or gunshot fractures, in which the cancellated structure is injured ; a severe contu- sion of the bone, an injury to the periosteum, or exposure to sudden extremes of heat and cold is capable, under some circumstances, of produc- ing the disease. Symptoms. — The symptoms are obscure, more especially if there be no opportunity of examining BONE, DISEASES OF. 127 the affected boce, as the changes in the bone are often masked b; inflammation of the superficial parts. They usually make their appearance from five to ten days after the injury to the bone. The pain may not be excessive ; there is fever and perhaps rigor. If there be 4 -wound the secretion ftom it diminishes in quantity, and be- comes less healthy; the medulla protrudes from its central cavity ; the parts soon become surrounded by putrescent fluid ; and the symptoms become those of more or less intense* septiciemia. The periosteum sometimes, but not always, separates from the bone. In young persons the disease is sometimes arrested at the epiphysis ; but in the adult the ■whole length of the bone is liable to be affected. The risk of septic poisoning is infinitely greater in osteomyelitis that in osteo- periostitis. Thrombosis of the bone-veins is especially prone to happen, and by the breaking down of the clot septic emboli are carried into the circulation, and deposited in the liver, lungs, and elsewhere. It is in this disease, too, that fatty embolism takes place — a condition associ- tited with a very acute and fatal form of blood- poisoning. The prognosis is generally bad. It is impossible to distinguish acute osteomyelitis from acute osteo-periostitis, arising from non- traumatic causes. In military hospitals, in war time, acute osteo-myelitis is often epidemic TBEATMENT.-.-Where the symptoms lead us to suspect osteomyelitis, although the medullary ' cavity of the bone may not have been exposed, it may be desirable to trephine the bone, and if suppuration in its interior be discovered, it will be necessary to amputate, and as soon as the nature of the disease is recognised, this affords tlie best chance of saving the patient's life. The chief difficulty consists in arriving at a correct diagnosis and deciding when it becomes necessary to interfere. This may best be done by obser^'ing the general progress of the case ; and locally by the introduction of a probe into the medullary cavity when this is exposed. If it reach healthy bleeding medulla near the surface, we may temporise, if the constitutional symptoms admit of Uiis ; but it is rare for the disease once commenced to be limited — it has an extreme tendency to become diffused. Ex- perience shows that nothing short of amputa- tion at, or even above, the next joint is sufficient to arrest the consequences of the malady, and this must be done before the systemic poisoning has become marked. Amputation in the con- tinuity of the affected bone is worse than use- less. (A) Chronic osteomyeUtia is an obscure affec- tion, not to be distinguished, either clinically or pathologically, from chronic ostitis. It may ter- minate in sclerosis, or in the formation of an abscess. .«. it does not lead to much difference in the sets of symptoms produced) whether we have to do with a case of haemorrhage into, or ■with a case of softening of the brain. Thus the 'locality' and extent of the lesion in the case of a local disease of the brain has always to be enquired into as a problem altogether apart from that as to the more or less distinct nature of the pathological change in the part affected. In other words, theproblem of diagnosis in brain disease is twofold; it must have reference to the region affected (Regional Diagnosis) and to the pathological cause (Pathological Diagnosis). The causes interfering with the progress of our knowledge in the former direction are both numerous and bafiling, so that, as yet; compara- tively little progress has been made. Symptoms, — The most Aequent effects or symptoms of functional or structural brain-dis- ease may be thus classified : — 1. Pee^vehted Sensation and PEECBPTioif. — The special senses of smell, sight, hearing, touch (fifth nerve), or taste may be interfered ■with by diseases of their respective nerves or primary ganglia ■within the cranium. Owing to the decussation of the optic nerves, disease of the optic tract gives rise (most frequently) to an affection of the sight of the opposite eye. The sense of taste pertains to different nerves. Thus the glosso-phaiyngeal has to do with this special sensation in the back part of the tongue, the palate and fauces ; whilst the taste- nerves for the front part of the tongue, though they pass from these parts -with, the lingual branch of the fifth, seem to leave it by the chorda tympani and then proceed to the brain with the facial or the fifth nerve. Disease of the intracranial portion of the fifth nerve may not affect the sense of taste, though it impairs the common sensibility of the tongue. Disease of the primary ganglia of these nerves, whether they are separate (first and fifth) or lodged in the brain-substance at its point of connection with the nerve, ■will produce decided impairment of the several special senses. But BKAIN, DISEASES OF. 133 disease of portions of the brain above these regions on one side only, even thongh very extenaire, often exists •without disturbing the exercise of the special senses on either side. There may, however, be Illusions, Hallucinations, or Delusions in connection with either of these senses in many functional and structural diseases of the brain, where the morbid condition is situa- ted in parts higher up than the primary ganglia, or where there is a functional exaltation of the ganglia themselves. This latter funptional ex- altation seems sometimes to be favoured by morbid states of some of the viscera — especially of the stomach, or of the uterus and ovaries. Disease in the brain may also impair the com- mon sensibility of the body, and in some of the most marked cases, this impairment is strictly limited to one lateral half of the body (Hemi- ansesthesia). It may be very marked and last for a long time ; or it may be slighter and present only for a few days. There are several modes of impressibility comprised under the term ' com- mon sensibility.' The principal varieties are tactile impressions, impressions produced by differences of pressure and of temperature, im- pressions yielding pain, and lastly those of the so-called ' muscular sense.' There is, moreover, a general sensibility pertaining to the muscles and joint-textures, and the last may be pro- foundly impaired in some cases. The writer be- lieves that what there is of conscious impression pertaining to that endowment known as the ' muscular sense,' is compounded of the ordinary sense of touch and pressure pertaining to the skin, plus sensations in joints and muscles ac- cruing from the contraction of the latter. Besides diminutions of sensibility, we often have to do with disagreeable sensations of numb- ness,, tingling, or actual neuralgic pains in parts. The two former may be widely distributed, though neuralgia from brain-disease is princi- pally limited to the territory of the fifth nerves. 2. Pebvbeted Emotion aio) Idkation. — These manifestations vary, from the mere in- creased tendency to emotional displays seen in a hysterical person or in persons suffering from hemiplegia, to those more complex aberrations met with in the various forms of delirium and insanity (see Insanity). 3. Pekvebsions of Consciousness. — Under this head may be included the comparatively rare states known as somnambulism, ecstasy, and catalepsy ; as well as the exceedingly common conditions of drowsiness, stupor, and coma. The former may be sa,id in almost all cases to be associated with functional rather than with structural disease of the brain ; at least, this is most in accordance with our present knowledge. Drowsiness, stupor, and coma are, however,, amongst the commonest results of organic dis- ease of the brain (see Consoioitsness, Disorders of ), though they are also common conditions in blood-poisoning — whether arising from fevers, nrsemia, or from poisonous doses of opium or of other narcotic or narcotico-irritant poisons. 4. Pebveesions op MoTiuTr. — These mani- fest themselves in many forms, which, however distinct they> may appear to be, are, neverthe- less, closely linked to one another. nemors may be general or local, and in the latter case they may be most marked in the tongue and facial muscles — principally those about the corners of the mouth or the orbicularis palpebrarum. General tremors may, arise from debility, over-exertion, nervousness ; or they may be due to alcoholic or mercurial poison- ing, or to degenerative disease about the pons and medulla, as in Paralysis Agitans. TwitcUngs may be characteristic of a highly nervous habit of body, and are especially fre- quent in some epileptics in the intervals between their fits, either in some of the facial muscles or in those of the neck or limbs. They may also occur in acute febrile affections, in which the functions of the cerebrum are involved, as shown by coexisting delirium, &c., and also in tho course of many organic diseases of the brain. In choipa the irregular movements of different parts of the body are often of this nature ; they may affect both sides of the body, or only one (hemichorea), . . Spasms ofa continuous or 'tonic' character are encountered in various diseases of the nervous system, such as laryngismus stridulus, trismus, hydrophobia, tetanus, hysteria, and some forms of hemiplegia and paraplegia. Such tonic spasms produce muscular rigidity, which has to be distinguished &om that due to chronic changes apt to occur in paralysed limbs. Clonic Spasms or Convidsions maybe either unilateral or general, and may be induced by the most varied causes. "When well-marked they are mostly attended by loss of conscious- ness, as in epilepsy and the majority of epilepti- form attacks. Co-ordinated Spasms, or movements of a strug- gling type, are met with in many epileptiform and hysterical paroxysms. Spasms of this type may be also limited to particular groups of muscles, as in the coi^'ugated deviation of the eyes and neck occurring in hemiplegia, in wry- neck, in writer's cramp, and other allied affections. Paralysis may be local and limited in seat to some of the ocular muscles, the muscles of mas- tication, the facial muscles, those of the tongue, or to parts supplied by the spinal accessory and pnoumogastric nerve, in those cases in which there is merely an implication of the intra- cranial portion of one or more of the motor- cranial nerves ; or it may take an incomplete or a complete kemipleffio type, with lesions limited to one half of the encephalon; or it may be general, and involve both sides of the body, if a large lesion exists in the pons Varolii, or if the functions of both cerebral hemispheres or their peduncles are gravely interfered with. In some of these cases, and especially with right-sided paralysis, various difficulties exist in giving expression to thoughts by means of speech or writing (see Aphasia). Deficient action of the will (without obvious structural change of the cerebrumj may cause paralysis in hysteria and allied states. Defective Co-ordination of muscular acts is met with, as in stammering and in some hemiplegie defects of speech ; also in the body generally in some cases of cerebellar disease, producing a peculiar and unsteady gait (titubation) closely resembling that which may ,be met with in alcoholic intoxication. Similar motor disturb- 131 Bnees may be induced by vertigo of -i^ell-marked extent. Vomiting, again, is a reflex motor act due to impaired co-ordination, -whicli occurs in many forms of brain-disease. More rarely the sphinc- ter ani and the sphincter vesica become relaxed, or the bladder may be paralysed. But incon- tinence of fffices or of urine, or inability to void the urine, are comparatively rarely met with as a result of brain-disease, except in the comatose state, or in patients who are more or less demented. 5. N-OTKiTivE OE TkophiC CuAiTGES. — With lesions in the motor tract of the brain in or below the corpus striatum a band of degenera- tion is produced, occupying part of the eras cerebri, the pons, and the medulla on the same side, and (below the decussation of the pyramids) the opposite lateral column of the spinal cord. This M one of the most important of the trophic changes occasioned by brain-disease, because the degeneration in the lateral column of the cord is apt- to spread to the contiguous grey matter, and thus to give rise to some, of the trophic changes prone to ensue in paralysed limbs. Trophic changes in other organs occasioned by some severe lesions in the brain appear as low inflammations and congestions of the lungs, or as hEemorrhages into these organs ; also as haemorrhages beneath the pleura or endocardium, or even into the substance of the suprarenal capsules or kidneys. Again, we may have acute sloughing of the integument in the gluteal region on the para- lysed side, dropsy of paralysed limbs, inflamma- tions of joints and of the main nerves of paralysed limbs, and, though more rarely, marked atrophy of paralysed mtisdes. Eetard- ation or arrest of growth is also apt to occur in paralysed limbs, when we have to do with infants or young children, suffering from severe organic brain-disease. Blanching of the hair, or altered pigmentation of the skin, also occurs not unfrequently in con- nection with brain-disease or violent mental emotions ; whilst in the insane the nutrition of the bones and of the pinna of the ear is apt to be interfered with. 6. Pebvekted VisCBBAX ACTIONS. — Exalted activity of the uterus, bladder, intestine, stomach, or heart, may be occasioned by functional brain- disturbance more especially; whilst the same brain-conditions may give rise to depressed or exalted activity of the liver or kidneys. "With other functionally disturbed or emotional brain- states there may be a lowered functional activity of the salivary glands, of the heart, of the respira- tory organs, of the organs of deglutition, of the organs of digestion, or of the sexual organs. Those are only to be taken as mere indications of the kinds of modiflcatioh that may be pro- duced in visceral activity by brain-disease. Much doubtless remains to be learned in this direction. It seems fltting here also to mention those contractions and dilatations of vessels which are apt to take place in different parts of the surface of the body, or in internal organs, from stimu- lation or contraction of vaso-motor nerveS, bo- casioned either by direct or indirect influence exerted upon the principal vaso-motor centres in the region of the pons Varolii. These contrac- BEAIN, DISEASES OP. tions or dilatations produce correlated alterations in the temperature, sensibility, and functional activity of the parts or organs affected. The temperature of paralysed parts, as well as the general body temperature, in the apoplectic state is subject to great variations, and these are ncT beginning to be studied more attentively. They are capable of yielding diagnostic indications of great value. Eemaeks.— Some general remarks on the subject of structural and functional diseases of the nervous system, showing how intimately these two classes of disease are related to one another, wiU be found in the article Nebvous System. Most of what is said there is applic- able to diseases of the brain in particular ; here, however, it is necessary to call attention to cer- tain points specially related to brain-disease. When paralysis occurs from brain-disease affect- ing one cerebral hemisphere, in the great majority' of cases it is situated on the opposite side of the body, owing to the fact that the fibres conveying the volitional impulses to tho muscles decussate) in the medulla oblongata. It is true that many cases are on record in which the paralysis either has, or has been said to have existed on the same side as tbe brain-lesion. A certain number of these cases are probably due to errors eitlier in the clinical or in the post-mortem .records of the case. Others, however, still remain unexplained. The characters of the various forms of paralysis due to brain-disease are briefly set forth in the article on Paealtsis. Lesions of the left hemisphere much more fre- quently than those of the right, are associated with aphasio defects of speech; whilst, accord- ing to Brown-Siquard, lesions of the right hemi- sphere are more frequently" and rapidly fatal than otherwise similar lesions of the left hemi- sphelre. They are also more apt to be associated with acute sloughs of the skin on the paralysed side. Convulsions at the onset, and subsequent tonic spasms of the paralysed limbs, are also said to be more frequently associated with left- than vrith right-sided paralysis. Congenital atrophy of one hemisphere, or atrophy occurring in early infancy, is mostly associated with an arrest of growth and develop- ment in the limbs on the opposite or paralysed side of the body. Very little is positively known concerning the diseases of tho cerebellum. Of its fiinctional affections we may be said to know absolutely nothing. That is, of the various functional dis- eases of the nervous system vrith whose clinical characters we are familiar We are unable to name even one which we can poSitiTcly say is a func- tional disease of the cerebellum. Whatever the precise mode of activity of the cerebellum may be, there is a general consensus of opinion that it is principally, if not exclusively, concerned vrith motility, and that it has more especially to do with the higher co-ordination of muscular acts. Atrophy of one hemisphere of the cereljrnm is followed by atrophy of the opposite half of the cerebellum, so that there is ^strong presumption that the functional relationship of either half is with muscles on the same side of the body. Clinically we know that disease of the cerebel- lum ' is not unfrequently associated vrith more BKAIN, DISEASES OF. or less marked paralysis on the opposite side of Ihe body; but this effect is now generally attributed to the pressure which structural dis- eases . of the cerebellum are apt to occasion on the pons and medulla of the same side. Etiology. — The principal modes of causa- tion of diseases of the brain may be thus sum- marised : — 1. Defective Nutrition operates by modifying the proper constitution of nerve-tissues as well as the constitution of the blood, and thereby in- terfering with the normal functional relations of the several parts of the brain. Ansemia, chlorosis, syphilis, ague, and all lowered states of health, howsoever induced, and whether acquired or in- herited, become predisposing or actual causes of brain-disease. To these states!, favourable to the manifestation of brain-disease, should be added the various acute specific diseases, ursemia, metallic poisoning, poisoning by tl(e narcotic and narcotico-irritant poisons generally, and also by the occasional qualities of certain articles of food, such as mackerel, mussels, mushrooms, &c. 2. Emotional Shocks cause cerebral disorder, especially in children, or prolonged overwork in those who are older — particularly when com- bined with worry and anxiety, with sexual ex- cesses, or with protracted lactation. Beligious excitement, again, not unfrequently leads to in- sanity. 3. Phj/siolopcal Crises, such as the period of the first dentition, the period of puberty, preg- nancy, and the climacteric period, all favour the manifestations of various nervous diseases. i. Visceral Diseases or surface-irritations (especially in children or in-persons having a very sensitive and mobile nervous system) may give rise to varied nervous diseases. Thus we may have convulsions or delirium in children from the presence of worms or other irritants in the intestines, or convulsions in adults during the passage of a renal calculus. Again we may have the phenomena classed as hysteria, or we may have Nymphomania, in consequence of certain states of the sexual organs. Cases of paralysis are said also to have a reflex origin occasionally, though tiis must be a very rare event. With much greater frequency we find surface-irrita- tions of various kinds leading, as in Dr. Brown- SAquard's guinea-pigs, to epileptiform attacks. 5. Structural lesions of the brain itself give rise to a very large proportion of its diseases. The various kinds of change will be fonnd enu- merated under another heading {see Neevods System). Haemorrhage and' softening are the most common and, therefore, the most im- portant of these morbid conditions. 6. Brain-diabase may be determined by the action of Heat {insolatw), especially when com- bined with fatigue and deficient aeration of blood. A somewhat siihilar brain-affection, however, is occasionally developed in the course of rheu- matic fever or in that of one of the specific fevers, 'in which the body-temperature rapidly rises to a lethal extent (109°-111° F.). 7. Concussions (whether from blows or falls) may give rise to brain-disease, even where no traumatic injuries 'or lacerations of the brain are produced. TuBATMESt. — The treatment of brain-disease BEAIN, ABSCESS OF. 186 will be discussed under the articles Nervous System, Pabaiysis, Convtlsions, and those on the several special diseases which will now be described in alphabetical order. H. Chaeiton Bastian. BKAIIT, Abscess of. — This term is applic- able whenever a circumscribed collection- of pua is formed in any part of the cerebral mass. JEtiology and Pathology. — Amongst the most frequent causes of cerebral abscess are severe injuries to the skull, disease of the temporal bone in connection with the ear, ligature or obstruc- tion of a main artery, and pysemift. Under the three first-named conditions the abscess is usually solitary, but from pyaemia multiple abscessea often result. For practical purposes we may per- haps conveniently discard the latter — since the symptoms will usually be those of general ence- phalitis — and confine ourselves to those cases in which single large- sized collections of pus are met with. With this limitation, abscess in the brain is by no means of frequent occurrence. The best marked, and ' also the more common examples of large brain-abscess are met with in connexion with compound fractures of the skull, and by far the most definite symptom which de- notes them is the formation of a fungus cerebri. Unless in a compound fracture the brain be directly injured and the dura mater torn, it is very rare indeed for any suppuration in its sub- stance to occur. It is not to bo denied, however, that now and then, after severe concussion or laceration without external wound, abscess may follow. In such cases we may conjecture that usually some slight laceration or extravasation occurred in the first instance, which constituted a focus for the inflammation. Abscess after simple concussion without lesion is probably a most rare event. In the article Brain, Inflammation of, we shall have to define Encephalitis as a dififiise change of a large part of the cerebral mass, per- haps of a whole hemisphere, attended by the infiltration of cells and fluid. It is obvious that the term abscess in the brain is applicable to one of the results of encephalitis, but it seems clinically probable that the two classes of cases are for the most part distinct, and that difiiiBe encephalitis has but little tendency to result in abscess, and that abscess is rarely preceded by a Stage of encephalitis. Both are usually the con- sequences of local injury to the brain, or of ex- tension from local disease of its coverings ; but whilst encephalitis probably resembles the ery- sipelatous type of inflammatory action, in loca- lised abscess this tendency is not present. Having distinguished brain-abscess from ence- phalitis, we must next say a word as to the risk of confusing it with intra-cranial but extra- cerebral collections of pus. Encysted collections of matter may be met with either between the dura mater and bone ; or within the arachnoid cavity; and perhaps it ought to be added, though with some hesitation, beneath the arachnoid, in the pia mater. Not unfrequently inflammation of the membranes precedes and attends the foi^ mation of an intra-cerebral abscess, and in these cases the symptoms will be mixed. In dealing with published cases it is also necessary to be on our guard as to certain errors which have crept 136 BRAIN, ABSCESS OF. in — cases of meningeal abscess being spoken of as brain-abscess. Mr. Prescott Hewett has ex- pressed his opinion that the celebrated case of De la Peyronie's was an example only of extra- cerebral abscess. It is absolutely necessary to make these restrictions if we would judge cor- rectly as to the symptoms which attend local collections of matter in the brain and the usual terminations of such cases. Symptoms. — The symptoms of local suppura- tion in the brain will vary with the stage, the size of the collection, its precise situation, and, above all, with the presence or otherwise of a fistula of relief. In many of the cases which come under surgical care a fistula exists from a very early period, though not unfrequently it is liable to occlusion. Under the latter conditions the symp- toms of a closed and an open cerebral abscess may be alternately studied in the same case. It wiU usually be observed that when the exit is closed, and the abscess fills, the patient complains more or less of headache, becomes heavy and drowsy, experiences twitchings or spasms in the opposite side of the face and limbs, with some ten- dency to hemiplegia. Of this group the tendency to spasms is probably by far the most significant. The headache may be but trifling, and the pa- tient may even be well enough to leave his bed, when the occurrence of spasm followed by pare- sis alone gives warning of what is going on. The cases now alluded to are chiefly those in which abscess results from compound fracture of the skull with laceration of the brain-sub- stance. In these the abscess often gives way spontaneously, and a fistula forms, around the orifice of which a mass of pouting brain-granu- lations, known as fungus cerebri, usually forms. In these cases the canal of communication may be very tortuous, and the liability to blocking considerable. Now and then the same result may be met with after syphilitic disease of the skull and meninges. The writer had some years ago a man under his care in whom he had opened a cerebral abscess beneath a hole in one parietal bone. The patient was able to walk about, and ailed but little so long as the fistula was freely open ; but spasms of the face, or even convulsions of the limbs (on the opposite side) always fol- lowed its occlusion. The softening gradually extended, and he at length died in consequence, perhaps, of the impossibility of making a counter- opening in a, depending situation. Unless the abscess be in the anterior lobe, there will almost invariably be present some degree of hemiplegia, but this will of course vary with the size of the collection and the extent of destruction of tissue. The formation of an abscess after injury is some- times very insidious, the symptoms being very slight. , The cases in which violent headache and pain, vomiting, delirium, and dry tongue, are said to have been present in the early stages are, the writer suspects, usuaEy instances of suppuration between the bone and dura mater. These symptoms occur especially when brain- abscess follows disease of the internal ear, and in these there nearly always is the complication of inflammation around the petrous bone. Such uymptoms are very rarely present in traumatic ubscesses, which often develop very quietly •ii;til they attain a considerable size. It is pro- BEAIN, ASMMJA OF. bable that some degree of rigor, attended by rise of temperature, usually occurs in the begin- ning of cerebral abscess, but no very precise data are extant on these points. The contents of a brain-abscess usually con- sist to some extent of broken-up cerebral tissue, and in some cases there are but very few pus- cells. Especially is this likely to occur when the so-caUed abscess follows on ligature of the carotid or occlusion'of a cerebral artery. In these oases, it is in the first instance at least the result of a process of softening rather than of true suppuration. If a large abscess be permitted to develop without relief, the symptoms of compression will in time ensue : first spasm, then hemiplegia, then hebetude and coma, preceded possibly by violent convulsions. Diagnosis. — The diagnosis between cerebral abscess and meningealabscess is exceedingly diffi- cult, and often a guess is all that can be made. The almost invariable occurrence of spasm or con. vulsions in the former, and their frequent ab- sence, with the greater degree of pain and head- ache in tho latter, are the most reliable signs. Sometimes — as, for instance, when trephining has been practised, and no inflammatory products are found between the bone and dura mater or under the latter — the diagnosis may be helped by this negative knowledge. In such cases, if hemir plegia, preceded by spasm, have been gradually developed, the surgeon wiU be well justified in making an incision or puncture into the hemi- sphere. Optic neuritis may equally be present in both, and its presence or absence will scarcely help the diagnosis. Peoonosis. — In addition to the danger of death by compression, there is the risk that the abscess may break into the ventricles or into the subarachnoid space. Some cases are on record in which spontaneous openings into the nose or into the ear occurred, and profuse discharge followed, the patient in the end recovering. It may be doubted whether these were not instances of meningeal abscess. Tkea,tment. — It is needless to say that if ab- scess be diagnosed vrith any degree of confidence an opening is essential. There is little or no room for medical treatment. For the prevention of abscess, in all cases in which injuries likely to produce it have occurred, the utmost precautions should be enforced. Mercury in small doses, fre- qently repeated, should be given from the first ; the injured region should be covered with lint soaked in a strong spirit-of-wine lotion, frequently re- wetted; purgatives should be administered; and the patient should be kept very quiet until long after the healing of the wound. Jonathan Hutchinson. BBAIIT, Aneemia of. — Definition. — A con- dition in which the blood contained within the capillaries of the brain is deficient in quantity, or defective in quality. ■ The blood within the brain is contained in arteries, capillaries, and veins. The functional condition of the brain depends on the quantity and quality of the blood circulating in its capil- laries, and it is to these that the special symptomb are related. Deficiency in the quality of the BRAIN, ANMUIA. OF. 137 blood supplied to the brain is always of gradual occurrence, andaffeots the ■whole brain; deficiency in quantity of blood may affect the vhole brain or part only, and it may be sudden or gradual in its production. JEtioloot. — General cerebral anamia may be due to the following causes ; — (IJ It maj^ be a part of systemic anaemia — defect in quantity or quality oi the whole blood, and due to causes which are considered elsewhere. This is often seen in cases of hteraorrhage, of exhausting discharges, or of defective blood-nutrition, as in chlorosis. (2) The supply of blood to the brain may be deficient, the quantity of blood in the body being normal. This may be due to cardiac weakness, or to causes acting through the nervous system on the heart, as in swooning. In systemic ansemia, the lessened cardiac power increases the cerebral deficiency. Whatever lessens the amount of blood discharged from the heart at each systole, such as aortic or mitral diseajse, may be a cause of cerebral ansemia. Pressiire on the vessels conveying the blood to the head, as by an aortic aneurism, has a similar effect. Unequal distribution of the systemic blood is another cause. The intestinal vessels, if dilated, are capable of containing a large part of the blood of the body, and the effect of their engorgement is often seen after paracentesis abdominis. One theory of shock ascribes its mechanism to vaso-motor dilatation of these vessels, and consequent anaemia of the rest of the system. The effect of each cause is increased by the action of gravitation in the erect posture. Some causes act only in that position. (3) The capacity of the cerebral vessels may be dimmished by pressure on the brain, exerted by effusions of fluid (hydrocephalus), of blood (in cerebral and meningeal hsemorrhage), or by growths within the skull. Partial cerebral anamia is due to some ob- struction to the passage of the blood through the vessels. To be permanently efBcient such obstruction must be situated beyond the circle of WiUis. Ligature of one carotid causes immediate symptoms of cerebral anaemia, but permanent symptoms are not frequent. Pressure on, or disease of one carotid, for the same reason rarely gives rise to symptoms. Obstruction in certain arteries of the brain may cause local ansemia, sudden or gradual, temporary or permanent, according to its cause. Such obstruction may be due to narrowing of the calibre of the vessel by atheromatous changes in its wall, or by spasm of its muscular coat, or may be due to actual occlusion by embolism or thrombosis. The pressure-effects of an intruding substance within the skull (tumour, or clot) act most intensely in, and may influence only one region of the brain. It is obvious that of these causes some act suddenly, others gradually, and the symptoms produced will differ aceor^ngly. Anatomical Chabactebs. — The principal anar tomioal character of cerebral anaemia is pallor of the brain, observable chiefly in the paler tint of the cortical substance, and the diminished number of red spots in the white centre. The pallor may be partial or general. The mem- branes are usually pale, but in some cases of partial anaemia they are hypersemic. Effusion of serum in the meshes of the pia mater and between the convolutions, may be found in general ansemia. Symptoms. — The symptoms of this condition vary according as the ansemia is suddenly oi slowly produced, and as it is general or partial. (1) In sudden, general ansemia of the brain the sufferer feels drowsy; the special senses are dulled ; noises in the ears and vertigo are com- plained of; the pupils are at first contracted; sight may fail ; muscular power is weakened ; respiration is sighing ; the skin is pale, cold, and moist ; nausea is common ; and headache is rare. If the ansemia is more intense, consciousness is lost; there is universal paralysis ; and general convulsions may occur, epileptiform in character, these being especially frequent in sudden exten- sive losses of blood in strong subjects. The pupils dilate, and the coma may deepen to death. The loss of sight in cases which recover may persist as permanent amaurosis. (2) When genilral ansemia of the brain is slowly produced, the stats of the cerebral func- tions IS usually that of 'irritable weakness,' Their action is imperfect in degi'ee, and excited with undue facility. There is, mental dulness and drowsiness ; sometimes, however, insomnia is troublesome. Delirium is common , in severe cases, and is conspicuous in some forms of im- perfect blood-nutritioH, as in the so-called ' inanition delirium.' Headache, usually general, is a common symptom. Sensory hyperassthesise, tinnitus, muscae volitontes, and vertigo are fre- quent. Convulsions are rare, but muscular power is generally deficient. All these phenomena are more marked in the erect than in the recumbent posture, especially when the erect posture is suddenly assumed. It has been remarked that some anasmic persons can think well only when lying down. In young children, after exhausting discharges, as diarrhtea, symptoms referable to cerebral ansemia are common, namely, somnolence and pallor, with depressed fontanello and con- tracted piipils. The somnolence may deepen to coma with insensitive conjunctiva, and the coma increase to death. Such symptoms have been called hydrocephakid, from some resemblance to those of acute hydrocephalus. (3) Partial cerebral anaemia causes, if complete, loss of function in the affected area ; and if it be permanent, as in obstruction of a vessel beyond the circle of Willis, necrosis of the cerebral tissue results (see Beain, Softening of). If incomplete and sudden, there is temporary arrest of function. Ligature of one carotid, for instance, causes transient weakness and numbness in the opposite half of the body. There may be at first an over- action of grey matter, causing, in certain regions, unilateral convulsions. If slowly developed, as in atheroma of arteries, pain and vertigo are common, with recurring local symptoms, such as numbness, tingling, and weakness. In all cases of long-continued cerebral anaemia, permanent damage to the nutrition of the brain may result. In the child the development of the brain may be arrested; in the adult, loss of memory and of general mental power indicate the deterioration of structure. Pathology. — The symptoms are, as already stated.dependent mainly on the defective quantity 188 BRAIN, ANJEMIA OF. and quality of the blood circulating in the brain. Some influence may probably be ascribed to the diminution in the blood-pressure to trhieh the nerve-elements are ordinanly exposed (Burrows). I^othnagel has pointed out that the symptoms indicate an early affection of the respiratory centre in the medulla, and of the cortical grey matter. Kussmaul and Tenner ascribe the con- vulsions in acute anaemia to the irritation of the medulla ; Nothnagel, to that of the pons Varolii. DiAGwosis. — The diagnosis is not difficult. It rests on the recognition, in a given case, of the causes of cerebral anaemia ; and on the exclusion of graver maladies, as organic cerebral disease. With the latter, it should be remembered, atisemia of the brain, local or general, often co-exists. Some symptoms of hypersemia of the brain closely resemble those of anaemia. A common patho- logical state of imperfect blood-renewal probably ozists in both conditions. Peogkosis. — The extent to which the cause of the anaemia is amenable to treatment, and is of transient character, must influence the prognosis. As a rule this is favourable when there is no or- ganic disease of heart, vessels, or brain. In the so-called 'pernicious anaemia,' the prognosis is, of course, unfevouiable. Hydrocephaloid symptoms in infants, if met by prompt and suitable treat- ment, are usually recovered from. TKEiTKENT. — The treatment necessarily varies in the several forms of the affection, but it is in the main causal. The beneficial effect of the recumbent posture in affording immediate relief to the symptoms, and obviating permanent damage to the cerebral nutrition, must be always remembered. In acute anaemia from loss of blood, the head must be kept continuously low, stimulants freely administered, and as a penulti- mate resort bandages applied to the limbs from below upwards may increase the proportionate supply of blood to the brain. If this &il3 trans- fusion must be had recourse to. In chronic anaemia sudden change of posture should be carefully avoided, and ferruginous tonics are needed. In spa^m of the cerebral vessels, bro- mides are useful. In the cerebral anaemia of syncope, the recumbent posture, stimulants to the sHn, cold water, faradisation, sinapisms, and ammonia to the nasal mucous membrane, assist the recovery of cardiac action and the return of consciousness. In all cases, carefully . regulated food and stimulants are needed ; beef-tea should be given in small quantities, at frequent inter- vals. The group of symptoms called hydrocepha- loid require similar treatment. "W. E. GOWEES. BBAIIf , Aneurism of. See Brain, Vessels of. Diseases of. BBAIIT, Atrophy of. — Atrophy of the brain may be congenital, due to arrest of development in very early foetal life ; or the constituents of the brain may have been perfectly developed, and may subsequently disappear from one of several causes. This morbid state is regarded as primary when there has been no pre-existing disease of the brain or its membranes ; teoondary, either when there has been such pre-existing disease, and the atrophy has occurred from absorption of the part broken down by in- flammation, softening, haemorrhage, &c.; when BEAIN, ATEOPHT OF. atrophy of some special cerebral organ followf upon destruction of the particular nerve thai arises from it; or when localised atrophy hat taken place in a veiy gradual manner from pres- sure of a tumour, of ventricular, effusion, &c. To take these forms in order : — 1. Congenital atrophy. — This is usually asso- ciated with weakness of intellect, even to the extent of idiocy : there is atrophy of the body op- posite to the side of the cerebral lesion, and tlus atrophy involves all structures, even the bones. Paralyses of various intensity supervene, often with contraction of the paralysed parts ; there being no particular sensitiveness of the special senses, possibly because of the mental hebetude. Epileptic attacks are common ; vitality is low; and the patient easily succumbs to other diseases, 2. Primary atrophy. — ^In this variety there is general diminution both of volume and of weight, affecting most usually the cerebral hemispheres, and that in pretty equal degree. It is most common as a condition of old age — senile marasmtis, atrophia cerebri senUit. It some- times in earlier life follows exhausting diseases ; and may also be caused by deficient or impuro blood-supply to the brain. In close connexion with this mode of causation it is seen after re- peated attacks of intoxication, especially after delirium tremens- In this last conditioQ. the cerebral atrophy may be acute and rapid. .3. Secondary atrophy. — This may be general or partial. When general, the convolutions have a shrunken appearance, and there is always an increase of the subarachnoid fluid. This condition follows various lesions of the brain, especially of the convex surface, such as haemorrhage of the convexity, encephalitis, or more accurately that form of encephalitis that attacks only the grey matter or perhaps only one layer of the grey matter, as in eome mental diseases. When the atrophy is partial, there are found depressions in an otherwise normal hemisphere, at which point a localised haemorrhage or patch of softening, inflammatory or depending on thrombosis or embolism of vessels, has been absorbed, leaving only a cavity of greater or less extent, filled with fluid and sometimes lined with a thin membrane. A certain portion also of the brain may become atrophied by the gradual pressure of a tumour or any foreign body. Even the little sieve-like depressions seen in various situations after con- stantly repeated congestion of vessels may be the result of atrophy from compression by the distended vessels. Functional inactivity and atrophy of the optic nerves has led to a similar abnormality of the corpora quadrigemina» Anatomical Chabactees. — The atrophied brain or portion of brain will vary in appear- ance on minute examination, according as the lesion has or has not been preceded by inflam mation. When the atrophy is primary and due to gradual interference with blood-supply, there IS seen a shrunken condition of the nerve-tissue, especially of the calibre of the nerve-tubes. Tho cells are smaller than usual and pigmented, tho arteries being decreased in size or themselves diseased. If the lesion has had an inflammatory origin, the process in order of sequence is, first, inflammation, then softening with fatty degene- ration then partial absorption, and so atropliy; BEAIN, ATEOPHY OF. the appearances differing according to the stage of the lesion. Traces of fatty degeneration of all the tissues, — ressels, nerve-tubes, and cells, may be found> with the neuroglia either want- ing or sclerosed. Dr, Eudolph Arndt has lately thrown doubt on the possibility of determining atrophy of the ganglionic bodies or nerve-tubes by their size. The size of these bodies varies so greatly, within the limits of health, that he considers this test a very uncertain one. Almost the only trustworthy sign of atrojJiy, in his opinion, is the appearance in the substance of the ganglionic bodies and in thwmedullary sheath of nerve-bundles, of black shining globules, somewhat fatty-looking. In process of time these globules increase in number, and at last the whole of the bodies appear per- meated by them. These globules are not fatty, they are certainly more or less pigmental. Exactly similar bodies appear at post-mortem examinations, and are a sign of simple decom- position. The duration of this contoion, irre- spective of pre-existing lesions, is protracted. Stmptoms. — The symptoms of atrophy of the brain necessarily vaiy according to the seat, ex- tent, and Eetiology of the lesion. Primary atrophy of the cerebral hemispheres and the first form of secondary atrophy will most usually induce imbecility, or some lesser degree of mental in- BuflSciency, loss of memory, slowness of thought, and other mental diseases. Headache, giddiness, delirium, and stupor are seldom met with. In- terference with speech is more common. Affec- tions of sight, and of the motor condition of the eye, do not depend on general atrophy of the brain ; they own a more local cause. Convulsions, paralysis, stiffness of muscles, or contractions are often met with in connexion with this general lesion, as well as various irregu- larities of locomotion : but it must be remembered that general atrophy of brain is not seldom as- sociated with atrophic or sclerotic lesions of the spinal ford, and even where this is not so, several of the morbid phenomena, and particu- larly convulsion and paralysis, may derive their origin, not from the atrophy, but from the con- dition pre-existent to the ' atrophy, such as hsemorrhage of the convexity, meningitis, or peri-encephalitis. In secondary atrophy of amore limited extent, the symptoms are apt to be more strictly local- ised, sudi as partial loss of power in a single limb, shght imperfections of speech, or strabis- mus ; but here again the positive diagnosis of atrophy is hindered by the complieation of pre- existent disease, the local congestions, heemor- thages, softenings, tumours, or other conditions of which the atrophy is only the sequence. Still less characteristic are the phenomena attending general or partial atrophy of. the, cerebellum, the pons, and the medulla oblongata. Teeatment. — Treatment is useless as to the atrophy of the brain : it must be directed to supporting the powers of the patient. I , - E. LoNO Eox. BBAIsr, Carcinoma of. See Bbaik, Tti- mours of. BBAIU', Compression of. — The brain is compressed in the pathological sense whenever its BEAIN, COMPEESSION OF. 139 structure is so squeezed that its functions are in any degree interfered with. This squeezing may be effected either by the effusion of blood within the skull, the growth of a tumour, the accumula- tion of pus or serum, or lastly by the depression of some large portion of the bony parietes. The general belief that depressed fractures are fre- quently the cause of compression is probably quite a mistake. In such cases the fragment displaced is rarely of sufficient size to cause serious com- pression of the contents of the skull, and the symptoms usually supposed to indicate that state are really due in most cases to laceration and contusion, or to subsequent inflammation. This point is of great importance in practice, for upon its recognition depends much of the validity of the reasoning by which the operation of primary trephining in compound fractures is defended or condemned. It also offers a most serious fallacy as regards the interpretation of the symptoms due to compression. By far the best examples of uncomplicated compression of brain are supplied to us by the not very infrequent cases in which a middle meningeal artery is injured, and a large blood- clot is effused between the dura mater and bone. It is from observation of cases of this kind that the assertion is justified, that a very considerable intrusion into the skull is permitted without the production of any symptoms. No doubt the suddenness or otherwise has much to do with the results, but there seems good reason to believe that, as a rule, the brain*wLll easily accommodate itself to quantities not exceeding an ounce or two, and that usually so large a quantity as four or five ounces is required to cause death. It is very rarely indeed that a depression of bone in the least approaches such an extent of intrusion as this, and the majority of such cases are, as regards the amount of possible squeezing, quite trivial. The manner in which the accommodation is effected is by the removsJ of the fluid contents of the skuU, first the subarachnoid fluid, and secondly the blood. Of the blood-vessels the veins and venous sinuses are probably emptied first, and lastly the arteries and capillaries. A brain in a state of strong compression is an ex- sanguincd brain. In this respect, the brain in the last stage of compression differs very much from that in cases of insensibility from con- cussion or contusion. It by no means follows that because the brain is pale, the face should be pale also ; but it is perhaps usually the case that extreme compression so much enfeebles the heart's action that the pulse ia weak or flickering, the respiration shallow and irregular, and tlie skin pale and cold.. That, stertorous breathing, a laboured pulse, and a suffused and dusky countenance, are (as according to the clas- sical description) symptoms of compression, is probably for the majority ,of cases a mistake. .Such a group much more frequently denotes laceration, contusion, or central extravasation. H'or is it true that hemiplegia, excepting of the most transitory kind, is often due to compression. A clot of blood poured out over one hemisphere may, if rapidly effused, produce for a while weakness, of the., opposite limbs, but the brain mass is soft enough to allow of considerable yielding, and in. the course of a few hours the 140 BRAIN, COMPRESSION OF. effocta of the displacement will have become general, and not local. In a case recorded by the -writer in which a post-mortem; some weeks later, proved the presence of a large blood-clot, there had been partial hemiplegia without un- consciousness at first, but on the next day all trace of it had disappeared, and it never re- turned. In many of the cases cf bleeding be- tween the dura mater and bone, from the men- ingeal artery, the haemorrhage takes place on eeveral different occasions, with, it may be, inter- vals of a day or two, much as is often observed in wounds of arteries, such as the palmar arch. Thug the observer is able to appreciate the symptoms caused by different degrees of com- pression, and further proof is afforded that, if the intruded quantity be but moderate, the brain bears it without obvious inconvenience. Often at the autopsy it is quite easy to dis- tinguish clots of very different dates, and to feel sure that the original one was of considerable size. It is clear then that in speaking of the symptoms of compression we must allow for differences in amount of the compressing sub- stance, and also for differences in the rapidity or suddenness of its application. When compression is produced instantaneously, as by a large fragment of bone driven down, the case is almost invariably complicated by con- tusion. If paralysis or even insensibility be present, it is usually impossible to say to which lesion they are really due. We may, however, hold it almost certain,' from what we know of other cases, that the effects in such would be a temporary hemiplegia, with symptoms of shock if the depression were but moderate ; and insen- sibility, probably soon followed by death, if the depression were very great. The cases in which depression of bone has alone been sufficient to produce long-continuied compression with insensi- bility are possibly somewhat apocryphal. It is possible that compression under such circum- stances might be attended by stertor and la- boured pulse, but it is possible also that the pulse might be extremely feeble, the countenance pale, and inspiratory efforts weak and irregular. The depression of bone is perhaps the only condition which can be supposed capable of producing compression suddenly. When blood is poured out from a ruptured artery, the symp- toms come on rather gradually. The patient complains perhaps of headache, and then be- comes more or less confused in manner, his gait is unsteady, and the limbs on the side opposite to the injury show special weakness. Vomit- ing may occur and the weakened limbs may twitch, and unless, as is often the case, the intracranial bleeding stops, these symptoms are soon lost in a state of complete insensibility. With pale face, feeble pulse, and symptoms of shock. Convul- sions may now occur, and death often supervenes very quickly. In such a case the whole course of the symptoms may occupy less than an hour. The surgeon ought, of course, to trephine and let out the blood, and he must be prompt, or his patient may die during his preparations. More commonly this rapid termination occurs unex- pectedly after one or more previous attacks of temporary head-symptoms, and the patient may have appeared quite well in the intervals. In cases in which the symptoms progress without interruption, their rapidity, no doubt, depends upon the size of the vessel ruptured. Certain special symptoms will also depend upon the pre- cise position taken up by the clot which may chance to press upon special nerve-trunks as well asupon the brain-mas». In ordinary cases the clot IS beneath the squamous bone and the lower part of the parietal, and passes downwards into the sphenoidal fossa. In the latter region it may press upon the nerves going to the sphenoidal fissure; and it is of importance for the surgeon to know that dilatation of the pupil on the affected side is often produced. This important symptom is probably due to pressure upon the third nerve. There is - yet another class of compression- cases in which that condition is produced by the slow accummulation of the products of inflam- mation within the skull. Much will depend, as regards special symptoms, upon the position of the abscess, either within or without the brain. If in the substance of the brain, it must more or less disorganise its structure, and thus cause symptoms due to laceration as well as compres- sion. Under such conditions some degree of hemiplegia; with, probably, preceding spasms of limbs, can scarcely fail to be present. Now and then cases occur in which an irregular sinus leads into an abscess-cavity in the brain, and this sinus being sometimes free and sometimes blocked, the surgeon has repeated opportunity of estimating the effects of filling of the cavity. In such cases, headache, stupor, unilateral twitch- ing of limbs, partial hemiplegia, with, perhaps, vomiting, and, it may be, general convulsions, are the symptoms to be expected. The position of the abscess as regards different regions of the brain is also of much importance, but its discus- sion cannot be entered upon in any detail here, and it obviously concerns rather disorganisation of structure than simple compression. When a large accumulation of pus takes place between the bone and dura mater, the symp- toms produced are much the same as those caused by blood-dot. We must make, however, much allowance for the fact that these cases are almost always attended by meningitis, and thus the symptoms of compression are masked by those due to inflammation. Chronic abscess under the bone without arachnitis may occur now and then in syphilitic and other disease of the skull-bones, but such cases are veiyrare. Such cases will differ from those of haemorrhage in that the symptoms are always produced verj slowly. The writer once had the opportunitj of watching such a case, in which the patient died of compression, very gradually produced, and without any complication. The chief symp- tom was constant wearing headache, which pre- vented sleep. The man was pale and feeble, but not paralysed in any part, excepting that both eyelids drooped. He was ration^, but spofcfe slowly, as if in a state of partial stupor. During the last two or three days of life he had convul- sions, and finally, for twenty-four hours, he was in a state of increasing insensibility. Diagnosis. — It will be seen from what has been said above that the diagnosis of compression by symptoms is exceedingly diflicult, and that BRAIN. COMPKBSSION OF. the utmost use must in each case be made of the histoty of the case. In those of blood-compression after injury to a meningeal artery, there is almost always the fact that the patient betiyeeu the date of the injury and the supervention of symp- toms had an interval during irhich there ap- peared to be little or nothing the matter. This history is, if the symptoms have developed rapidly and -without the signs of inflammation, by itself conclusive for diagnosis. Under such conditions trephining ought to be at once resorted to, or possibly it might be yet- better practice to first tie the carotid artery. The diagnosis of abscess in the brain-sub- stance has already been discussed, and that of inflammatory collections from meningitis will be examined in its proper place (fee Mesisobs, Diseases of ). Tkeatment. — The treatment of compression of the brain is almost wholly surgical, and con- sists in the use of the trephine and knife to elevate depressed bone, or evacuate collections of blood or pus. Jonathak HciCHiKsoif. BBAIIf, Concussion of. — ^We class under the head ' Concussion of Brain ' all symptoms which result simply from the shaking, more or less violenliy, of the contents of the skull. It will be obviaiis,however,that most cases of severe shake of the brain are likely to be complicated by visible lesions. The skull may he broken and the brain may be contused, lacerated, or ecchymosed. It is liighly probable, however, that well-marked and even serious symptoms may be produced by shaking only, and without the existence of any lesion discoverable either by the unaided eye or the microscope. We must further clearly under- stand that this element of concussion {i.e. the re- sults of shake independent of lesion) enters into almost every case of injury to the head. Whatever be the other lesions, it is usually the fact that the brain has been more or less severely shaken. Thus it may easily happen in cases in which, conspicuous lesions are present, such as fracture of the base or local contusion, that stiU the results of the shake are the most important. It might be convenient if we were in the habit of spealang of most cases of severe injury to the head as Cotums- skin plu3 other ledona, with the endeavour to assign to ea«h added complication its proper share in the general result. These explanations are necessary before we put the question — Can concussion alone cause death? Although it> is highly probable that we ought to reply with a very confident affirmation, and to assert that it is very common for concussion to be the chief cause of the fatal event, yet it is very difficult to prove it, since the cases are extremely rare in which severe concussion is produced without some attending lesion. The symptoms caused by con- cussion of the brain may be studied in very nu- merous cases of very various degrees of severity, which yet recover perfectly. From what is observed in these, we may infer as to the part which concussion takes in complicated ca^es many of which prove fatal. The results of concussion may he divided into three stages —the first stage is that of collapse ; the second, that of reaction, or of vaso-motor paresis, or, if named from its most prominent BEAIN, CONCUSSION OF. Ul symptom, the sleepy stage ; the third is that of convalescence, or recovery. The symptoms of the first stage, or stage of collapse, vary with the severity of the case, but if at all well- marked consist in feebleness of pulse, pallor of skin, coldness of extremities, and dilatation of pupils. They may approach a condition which threatens immediate death. There is no stertor, for tlie respiration is too feebly performed. Al- though the collapse may be very great, the in- sensibility is rarely quite complete. It is of great importance in this stage to establish the negative as regards all forms of paralysis. If any non- symmetrical symptoms aie present, the ease is more than mere concussion. During this stage nothing should be done, except placing the patient in a condition of comfort, and preventing the cooling of the body. Stimulants, unless the collapse is extreme, should be avoided. After the collapse has lasted some little time (half-an- hour to two, three, or more hours), it begins to pass off. The patient moans, manifests discom- fort, turns on his side, and draws his knees up. Very often at this period sickness occurs, and it is almost invariable if the patient's stomach was full at the time of the accident. Consciousness is now usually restored, and, by rousing, the patient may be induced to speak, and will tell his name, &c. Gradually, during a period of some hours, the case slides on into the sleepy stage. The pulse is now relaxed and full, the skin is warm or even hot, the face may be some- what flushed, and the pupils are contracted. The patient is overpowered with sleepiness, and can only be awakened with difficulty. It is, however, always vnthin possibility to awaken him, and he usually rouses himself to -the calls of nature. Very commonly the pulse is irregular, especially if the patient, be young. At this stage again care must be taken to ascertain whether there are any non-symmetrical symptoms, any weakness of a limb,' of one side of the face, or of any single eye- > muscle. If the patient passes his urine or fseoes in bed, or if there is long-continued retention of urine, it is very probable that there is more than mere concussion— namely, laceration or contu- sion. The sleepy stage may last for a day or for a week, and it is in severe cases so well-marked that the patient's eyelids may be held open, and the pupils examined, without awaking him. During this stage the measures of treatment called for are spare diet, purgation, cold to the head, and quiet. When the sleepy stage passes off, the patient is left weary, torpid, unfit for mental effort, and often with distressing headache. These are the symptoms of the con- valescent stage, and they may last more or less for a considerable time. The patient should still be kept carefully quiet, no stimulants should be allowed, and purgatives should occasionally he used. Some of the symptoms present during the stage of convalesence may persist so long that they may rank rather as sequelse. Thus there may be for years nervousness, inaptitude for business, liability to headache, and peculiar sus- ceptibility to the influence of stimulants. As a rule, however.evenaftervery severe concussions, no such iU-results are left, but the patient re- gains after a time perfect cerebral health. Thia remark must, however, not be held to apply to 143 BHAIN, CONCUSSION OF. 3oncussion Tpheu received in railway aooidents; for in these cases there is a prospect of pecuniary compensation, and the sequelae are often severe, prolonged, and very peculiar. Jonathan HiTTcniNSOK. BHAIN, Congestion of. See Bbaik, Hypersemia of. BBAIIf, HsBmorrhago into. — Stnon. : Cerebral Apoplexy; Fr. Hemorrhagie ciribrale interstitielle ; Ger. Bimechlag. DEFiNiTioif. — ^Escape of blood, by ruptnre of a vessel, into the substance or cavities of the brain. Haemoirrhage into the meninges is separately described. Cerebral haemorrhage is commonly due to the rupture of an artery, very rarely to that of a vein. Occasionally, minute extravasations are caused by rupture of capillaries. Haemorrhage from arteries or veins may also be due to their laceration by injury. MnauotiY. — Arterial haemorrhage is usually due to the coincidence of weakened vascular wall and increased pressure within the vessel. The causes of these states may be regarded as the conditions predisposiny to cerebral hsemorrhage. Hereditary influence is sometimes distinctly seen, as a tendency to vascular degenei^tion, or to conditions which, as renal disease, produce such degeneration. Similarity of vascular distribution may also be inherited, and may de- termine the locality of strain, and, therefore, first of degeneration, and ultimately of rupture. Cerebral haemorrhage is most frequent after fifty years of age, but occurs at any age, though rare during the first half of life. It is nearly twice as common in men as in women. It is said to be more frequent in temperate than in tropical climates, in winter than in summer, and at high than at low elevations. Certain acquired con- ditions act as predisposing causes. Chronic Bright's disease leads to early and extreme de- generation of vessels, as well as directly to hypertrophy of the heart and increased blood- pressure : hence it predisposes powerfully to cerebral haemorrhage. In purpura and scurvy, cerebral haemorrhage occasionally occurs — it is said in consequence of acute vascular degenera- tion and increased blood-tension. The state of vascular repletion known as plethora was for- merly thought to be a frequent cause of cerebral haemorrhage. It probably does aid other causes, but rarely co-exists with the most ef&cient, and so takes a very subordinate position. Chronic alcoholism and opium-eating are said to promote vascular degeneration. The proximate causes of cerebral haemorahage are the weakened state of the wall of the vessel, and commonly some increase of blood-pressure. The vessel-wall is weakened by degeneration, and is often imperfectly supported in an atrophied brain. The increase of pressure within the ves- sels may be permanent, as in peripheral obstruc- tion, with or without hypertrophy of the heart; or temporary, as in excited action of heart, or impeded circulation during effort. These causes are considered more fully in the article on Bbaik, Vessels of. Diseases of. Haemorrhage from a vein is rare, except as the result of laceration by direct injury, op of ulcera- tion invading the vein secondarily. Varicose BHAIN, HiEMOEBHAGE INTO. veins in the pia mater may sometimes rupture (Andral). Capillary haemorrhage is usually due to venous obstruction, especially to thrombosis in a vein. Anatomical Appeaeancbs. — In intra-cerebral haemorrhage, the blood is extravasated into the substance or into the ventricles of the brain — into the latter usually by ruptnre of a previous extravasation within the cerebral substance. In the latter situation the blood occupies a cavity formed by laceration of the brain-tissue ; rarely, when very minute and 'oapillaiy,' by merely separating the fibres. In size an extravasation varies from that of a pea or even smaller, lip to that of the fist. The blood is clotted, and reddish-black in colour; and fragments of brain-tissue are mingled with it. The cavity containing it is often very irregular in shape ; its walla are uneven, present projecting shreds of lacerated brain-substance, and are blood- stained and softened — at first by imbibition of serum, and later by inflammation. Many small extravasations are often seen in the neighbour- hood of a larger clot. Usually there is only one large extravasation : sometimes, however, there are two or three. The extravasated blood exercises pressure; the convolntionsare flattened; the falx is bulged to the opposite side (Hugh- lings Jackson, Hutchinson) ; and the rest of the hemisphere is anaemic. The effused blood may tear its way into the lateral ventricle ; it then speedily distends both lateral ventricles and the third and fourth ventricles, and escapes by the openings at the lower extremity of the fourth ventricle, central and lateral, into the subarach- noid space. Or the blood may escape to the surface, infiltrate the pia mater, and tear its way into the subarachnoid cavity, often by a very small opening. It is rarely that the artery from which the blood has escaped can be detected. Occasionally the extrayasaticn can be traced to the rupture of an aneurism of some size. In other cases miliary aneurisms may be found on many vessels. The larger arteries ccmmonly present atheromatous changes. After a time the extravasated blood under- goes changes. The clot shrinks and gradually becomes, first chocolate, then brown, and ulti- mately a reddish-yellow ; and it then contains chiefiy fat-globules, pigment and other granules, and haematoidin crystals. The rapidity with ■vrfiich it undergoes this change is doubtftil, and certainly varies. It is said that the distinctive blood-colour has disappeared as early as the twentieth day. Meanwhile the walls of the cavity undergo changes. The inflanamation, in rare cases excessive, and purulent, is usually conservative, and leads to the formation of con- nective tissue. A firm wall is thus developed, the inner surface of which becomes smooth by the softening and removal of the loose fragments of brain-substance ; by this means a cyst is formed. It is said that connective tissue may extend across its cavity, and that in rare cases, the fluid being absorbed, the cyst walls may unite, and a cicatrix result. Such cicatrices are, however, much more frequently due to softening than to haemorrhage. It is asserted that a cyst may be developed in thirty or forty days undei favourable conditions. BRAIN, HiEMOREHAGE INTO. Hsemorrhago may occur in any part of the biain, but is more frequent in some situations than in others. The most frequent seatis the corpus striatum and the region just outside it : nearly half the intra-oerebral hamorrha^es are in this situation. Other primary seats, in the order of frequency, are the pons and peduncles, the cerebellum, the cortex, the optic thalamus (often affected by an extension of the hsemor- rhagefrom the corpus striatum), the posterior por- tion, and the anterior portion of the hemisphere. The frequent extravasation into and outside the corpus striatum, is explained by the vascular supply. (See Beain, Vessels of. Diseases of.) Traumatic haemorrhage occurs into and from a lacerated portion of brain, and is most fre- quently found on the surface, occupying mainly the middle of the conyex portion of each convo- lution, and some other regions much exposed to injury, as the surface of the temporo-sphenoidal lobe, and the under surface of the frontal lobe. Ventricular hasmorrhage sometimes results from traumatic rupture of a small vein on the surface of the corpus striatum (Preseott Hewett). Soft tumours (especially glioma) are some- times the seat of haemorrhage. The distinc- tion from simple hssmorrhage (sometimes diffi- cult) rests on their position being commonly one in Trhich cerebral haemorrhage is rare ; and on some gelatinous-looking tumour-substance being found, into -which hsmorrhage has not occurred, and -which has characteristic microscopic features. Other organs may be healthy, or present the changes -which have been mentioned as predis- posing causes ; the lungs are -usually secondarily congested, often intensely. Symptoms. — The occurrence of cerebral haemorrhage is indicated by cerebral symptoms of t-wo classes, the one general and more or less transient, the other local and more or less permanent. In addition to these there are sometimes premonitory symptoms ; and commonly general symptoms manifested by pulse, tempe- rature, &c., -which are secondary to the brain- lesion. Premonitori/ symptoms, somewhat rare, are those of altered cerebral function due to local vascular disease, headache, vertiginous feelings, local' -weakness or numbness, slight mental changes, and slight affection of speech (see BsAiN, Vessels of. Diseases of, and Bkaih-, Anaemia of). They are less frequent than in cases of softening, and more commonly precede cerebral haemorrhage in the old than in the young and middle-aged. The onset of haemorrhage is usually accom- panied with apoplexy, i.e. loss of consciousness and of po-wer of motion and of sensation, often -with relaxation of the sphincters and loss of reflex action (see Apopiexy, Obeebbal). These symp- toms are profound and lasting according to the size of the haemorrhage and its position ; being es- pecially marked in large and double effusions, in intraventricular haemorrhage, and in haemorrhage into the pons. In a case of moderate severity they last only a fe-w hours, and gradually pass a-way. In severer cases they may deepen until death occurs from failure of respiratory po-wer. Death is rarely very speedy, life being usually prolonged for some hours even in the most 148 rapidly fatal cases. In rare instances iil haemorrhage into the medulla, and also iii meningeal haemorrhage, death has occurred in five minutes, probably in each case from the rapid interference -with the respiratory centre. The temperature is at first lo-wered one or t-wo degrees, the pulse becomes less frequent, and the respiration slo-w. The Oheyne-Stokes respiratory rhythm often precedes death. After a fe-w ho-urs the temperature rises to the normal and in mild cases stops there, but in graver cases it rises above the normal t-wo or three degrees. In some very grave cases the initial fall or sub- sequent rise may be extreme and go on until death occurs, sometimes reaching 90° in the one case, and 107° or 108° in the other (BourneviUe). In slight cases of cerebral haemorrhage there may be no loss of conscio-nsness. Vomiting in such cases is not -unfrequent. In other rare cases of large haemorrhage, especially bet-ween the external capsule of the'corpus striatum and the island of Eeil (Broadbeut), the loss of con- sciousness comes on gradually, after other symptoms, as of shock, for example, have lasted for an hour or t-wo. These cases have been termed ingravescent. Local symptoms, often permanent, and al-ways of longer duration than the loss of consciousness, are present in all cases of circumscribed cere- bral haemorrhage, except in the rare instances in -which, by its central position in the pons and medulla, it causes directly bilateral effects only, -which are added to and intensify the gene- ral symptoms caused indirectly. In a unilateral cerebral lesion, the direct symptoms are unila- teral loss of po-wer of voluntary movement and often of sensation, accompanied sometimes -with convulsion or rigidity. These local symptoms may commence a fe-w minutes or longer before the loss of consciousness. They coexist -with the apoplectic condition, and may often be recognised, even during coma, by the flaocidity of the paralysed limbs, -which fall more helplessly than those of the opposite side ; by inequality of the mouth and of the pupils ; by conj-ugate deviation of the head and eyes to-wards the side of the brain iiy ured ; by convulsive movements ; and, as the apoplexy clears, by the detection of unilateral defect of sensibility. The coma passing a-way, these signs become more distinct, and all the symptoms of hemiplegia remain, varying in intensity and extent according to the position of the lesion. The apoplectic state may recur after its disappearance— a grave symptom, usually in- dicating that a fresh hsemorrhage has occurred in the same or the other side of the brain, or more frequently that the blood has escaped into the ventricles. In the former case the unilateral symptoms, conjugate deviation of the head and eyes, &c., are increased on the same, or trans- ferred to the opposite side ; in the latter the uni- lateral symptoms disappear, and general power- lessness and deep coma supervene, -with stertor, relaxation of the sphincters, lowered temperature, and impeded respiration. Death always ensues. Con-vulsion may be a conspicuous symptom at the onset or subsequently. It is usually unilateral in its course or commencement, be- ginning on the side paralysed, rarely affecting only the non-paralysed side. Where convulsion u< 144 BKAIN, H^MOEEHAGE INTO. cot met ■wit'i^ nmscular twitching or rigidity may occur. General or ■widely-spread rigidity or twitching points to a hilateral lesion; if with coma, to ventricular hsemorrhage. After a day or two symptoms of irritation about the cerebral lesion come on, such as head- ache, delirium, and rigidity in the paralysed limbs., During this period the temperature rises above the normal, and the pulse becomes quick. On their subsidence, these symptoms, if the lesion is slight, may be scarcely recognisable, and a stationary period ensues, at the end of which recovery of power over the paralysed limbs begins. In slight cases power may be recovered very speedily. Its return depends upon the structural recovery of slightly damaged tissue, and on other parts taking on an increased func- tion in compensation for that which is destroyed. The electric irritability of the muscles exhibits little change. Sometimes, however, when there is great irritation at the lesion propagated downwards to the cord, a marked initial increase in irritability may precede a considerable de- pression, coincident with rapid wasting. Ee- coveiy of power is rarely complete except in those cases in which the area of damage is very small; and when the damage is large and affects an important motor region, there may be no recovery, loss of power persisting, commonly with more or less ' late rigidity ' in the paralysed limbs. Slight permanent mental change often re- mains, and as the motor power is recovered, ataxic and other disorders of movement may supervene in the limbs which were paralysed, although much less commonly than after softening. Diagnosis. — The diagnosis of cerebral haemor- rhage rests on the symptoms of a localised cere- bral lesion, occurring suddenly. The conditions from which it has most commonly to be distin- guished are — congestion of the brain ; softening of the brain, embolic and thrombio ; and, some- times, tumour. For the distinction from it of other causes of apoplectic loss of consciousness, uraemia, post-epileptic coma, &c. see Apoplexy, Cebebral. From congestion the chief dis- tinction of cerebral hsemorrhage lies in the transient nature of the loss of consciousness ; and in the slightness and general character of the symptoms which characterise the former. Congestion generally, haemorrhage only some- times, comes on during effort : and the absence of history of effort is in favour of the latter. Similarly, the premonitory symptoms which are usually present in congestion, are generally absent in hsemorrhage. The loss of motor power, and the symptoms of cerebral shock, are much greater in haemorrhage than in congestion. It must be remembered that the two states fre- quently coexist. From softening consequent on embolism cerebral haemorrhage has also to be distinguished. The subjects of the latter are usually of an earlier age than those of haemor- rhage ; their vessels are healthy, but they have organic heart-disease, which is often grave. There may be evidence of embolism elsewhere, in spleen, kidney, or retina. Loss of conscious- ness may be absent in embolism, and the para- lysis often comes on deliberately. An exten- sive capillary embolism, causing deep coma, cannot be distinguished from haemorrhage. From eoftening due to thrombosis the distinction is often difficult. Age, and the state of the vessels, no longer serve as guides. The presence of chronic Bright's disease is in favour of hsemorrhage. The occurrence of previous hemiplegic attacks points to softening. In the attack, loss of con- sciousness is much more considerable, in pro- portion to the subsequent paralysis, in haemor- rhage than in softening. But the distinction on this ground is often very dif&cult, since loss of consciousness may be absent in slight hsemor rhage, and considerable in an extensive softening. A deliberate onset is in favour of softening, and so are much mental change and early rigidity. Paralysis of sudden onset, in cases of iunumr, may be ascribed to haemorrhage, to which it is indeed sometimes, but not always, due. Usually, enquiry elicits & history of gradual, long-con- tinued symptoms ; intense headache and optic neuritis are strongly suggestive of tumour. Haemorrhage into the substance of the brain is distinguished from meningeal hemorrhage by the pain and mental excitement being less con- spicuous, convulsion rarer, and by the presence of symptoms of a local lesion. Hamorrhage into the ventricles, which resembles meningeal haemorrhage in the generality of its symptoms, is usually distinguished by succeeding the symp- toms of a circumscribed lesion. Peoqnosis. — During the attack itself the prognosis in haemorrhage into the brain must be guided by the intensity of the symptoms, and by the place of the lesion, as far as that can be ascertained. Death is probable if the coma is profound or long-continued, and if the early depression, or the subsequent rise of tem- perature and pulse-rate is great. When the symp- toms indicate ventricular haemorrhage, or haemor- rhage into the pons, the patient will certainly die. Consciousness being recovered, and the danger of immediate death over, the freedom from much secondary pyrexia, from lung-congesiion, and from bedsores, are favourable indications. The chance of recovery from the paralysis is es- timated by evidence of position of the lesion, and by any indications of improvement. Early contraction of the flexors is unfevourable. The danger of recurrence is in proportion to the ex- tent of vascular disease, and the existence of irremovable causes of increased arterial tension. Hence the prognosis is rendered unfavourable by advanced age, or chronic renal disease, and by the evidence of general premature decay. Teeatment. — During the attack. Best is the most important. The patient should remain, as far as possible, where he is seized ; stillness must be secured: and all effort is to be avoided. The posture should be recumbent, with the head raised. Any cause of passive cerebral congestion, such as a tight collar, must be looked for and re- moved. Venesection was formerly almost always emplojredin such cases— certainly too universally ; but it is now quite discarded — perhaps too abso- lutely. Loss of blood lessens the force of the heart and vascular tension j it thus hastens the cessation of external bleeding. Doubtless it acts in the same way in internal hsemorrhage. It may be used with probable advantage if the arterial tension is great (that is if the pulse is incompres- sible), the heart acting strongly, and there JD BRAIN, HjEMOREHAGE INTO. jteagon to believe that the intra-cranial haemor- rhage is increasing. A small qjiantity of blood should be taken rapidly. In veniricular hsenior- rhage, venesection is probably poverless for good. It should not be employed \rhere there is any evidence of failing heart-power. Its indications are drawn as much from the state of the patient as from the fact of heemorrhage. Bright's disease is no contra-indication. If bleeding is not employed, the objects to be aimed at by other measures must be to divert the blood as far as possible from the brain, by relaxing the systemic vessels, while endeavouring to obtain contraction of the cerebral vessels. ''Varmth may be applied to the limbs, aided by smapisras. Dry-cupping to the surface, and purgatives, as crotonoil, will divert the. blood to the surface, or to the capacious intestinal vessels. Drugs which would cause contraction of the vessels are to be avoided, since their iniiuence being on the smallest vessels and universal, their tendency is to increase arterial tension and haemorrhage. Contraction of encephalic vessels may be furthered by cold to the head or sinapisms to the neck, according as the head is hotter or colder than normal. The heart should be allowed to fall a little below the normal in force, but failure of power must be warded off by stimu- lants given with great care. Convulsion is more effectually checked by cold than by bromides; the latter may be given if the convulsion recurs. After the attaok. — During the stage of irrita- tion, rest must be maintained, and all sources of annoyance must be avoided. The bowels should be kept gently open by laxatives or by injec- tions. Stimulants must be avoided, and the diet should be light. Pain may be relieved by cold to the head, a blister to the neck, or by Indian hemp or by bromide of potassium. During reparation the diet must be nutritions, but carefully regulated ; and constipation of the bowels must be avoided. Rubbing of the limbs, and their gentle . exercise, will aid their recovery, and after the symptoms of irritation have' passed, faradisation will improve muscular nutrition, and is especially indicated where rapid loss of irritability indicates probable wasting. Nervine tonics are useful ; none more so than a combination of hypophosphite of soda and tinc- ture of nux vomica. In anaemia the syrup of the phosphate of iron is good. Warmth, change of scene, and cheerful mental surroundings are useM ai^'uncts, especially in the later stages of recovery. W. E. Gowebs. BBAIIT, Eyperffimia of. — Synox. : Con- gestion of the brain. Definitiok. — Increase in the quantity of blood within the capillaries of the brain. Since neither the arteries nor tlie veins of the brain-iSubstance can be over-distended vrith blood without capillaiy hyperaemia, and since it is to capillary hyperaemia that the functional disturbance of the brain is related, this may be justly taken as the essential pathological element in cerebral congestion. The congestion may be active, when the capillaries contain, in conse- quence of arterial distension or dilatation, oxy- genated blood passing rapidly through them ; or «t may be passive, when, from venous obstruo- 10 BRAIN, HYPER-SIMIA OF. 149 tion, the capillaries contain slowly-moving blood, becoming, and in great part already, venous. .iETioLooY. — (A) Active congestion of the brain may be general or partial. Of the general form the remote causes are as fallows : — Men are said to be more liable to it than women, Age in- creases its frequency (but this is more true of the passive form) ; yet children, from the sensi- tiveness of their vaso-motor system, ocoasionallj suffer from active cerebral congestion. Heredity has only an indirect influence. The plethoric condition is a powerful predisponent. The im- mediate causes of excessive flow through the arteries of the brain may be thus stated — ^(1) In- crease in the blood-pressure — either general, from excessive action of the heart (as in extreme hypertrophy or functional overaetion); or partial, from an obstruction elsewhere, throwing an un- due proportion of the pressure upon the cerebral vessels. This is seen in contraction of the aorta beyond the origin of the vessels to the head, and in sudden contraction of a large number of the systemic arterioles, as those of the surface, in exposure to cold and in ague. (2) Active ar- terial dilatation of vaso-motor origin may result from prolonged mental work, severe ■ moral emotion, insolation, digestive disturbances, or from the presence in the blood of various poisons, such as alcohol and amyl-nitrite. In these cases the vaso-motor disturbance may precede and cause, or may succeed and result from the overaetion of the brain-tissue, which is intensified by it. In acute alcoholic poisoning the cerebral congestion is, as Niemeyer suggests, probably secondary to the disturbance of brain-tissuo ; in chronic alcoholism it may possibly be pri- mary. In pyrexia the headache and delirium have been thought to be due to congestion, but this is not certain. (3) Increased atmospheric pressure may cause congestion of the brain. (4) And, lastly, gravitation in the recumbent posture may alone cause cerebral hyperaemia, or may powerfully aid other causes in produc- ing it. Fartial active congestion of brain-tissue occurs chiefly along vfith disease of the arteries, which perverts blood-pressure; in organic brain-dis- eases, as tumour, haemorrhage, &c. ; and after blows on the head. (B) Passive congestion of the brain, when general, is the result of impeded return of blood from the head. It may be due to pressure on the veins in the neck, as by tumours or tight collars ; pressure on the innominate veins by tumours or aneurism ; or obstruction to the circulation from violent respiratory efforts, as cough or blowing wind-instruments. It may be caused by impedi- ments within the circulation, such as tricuspid insufficiency and its causes in the lungs, or dis- ease on the left fide of the heart. The recum- bent posture assists all these influences. In arterial obstruction from diseased vessels, a weak heart, insufficient to overcome the obstruction, may permit venous stasis, but the capillary con- dition is one of angemia. Partial jiassive congestion may occur from thrombosis in a cerebral vein, or from pressure by a growth on one of the cerebral sinuses, AjfATOMioAL Appeabances. — The capillaries are not visible to the naked eye even when oret- 146 BEAIN, HYPEREMIA OF. distended, but with the microscope they are seen to be dilated, often to twice their normal calibre. Their distension is indicated by a deeper tint of the grey substance ; and the fullness of the small arteries and veins shows itself in an increase, often very great, in the number and size of the red points visible on section of the white matter. In active congestion the arteries are said to be distinctly larger than normal, and their perivas- cular spaces lessened in size ; the minute vessels of the meninges are distended. In passive con- gestion the veins and sinuses are gorged with blood. It must be remembered, however, that such engorgement of the veins occurs in all cases of death from interference with respira- tion, and that the vessels of the most dependent portion are always fullest. The state of the cerebral veins must therefore be carefully com- pared with that of the veins of other organs. Active congestion may sometimes leave no visible traces. After a time blood-pigraent collects out- side the vessels (Bastian), and serous effusion into the pia mater may be found ; and after long- continued congestion, the vessels may be perma- nently distended ; the spaces in which they run are increased in size. Such increase is common apart from pathological congestion, but it is so great in some cases of long-continued congestion that this effect cannot (with Moxon) be altogether denied. STMPToas. — It is probable thatmany symptoms have been erroneously ascribed to cerebral con- gestion, some because hyperaemia, due to the mode of death, was found post mortem, others because an assumed congestion was the readiest mode of explanation. Moxoh has indeed main- tained that cerebral hypersemia never causes symptoms except perhaps in death from strangu- lation. It is doubtful whether our knowledge of the conditions of the cerebral circulation is suf- ficiently exact to justify this conclusion, which is difficult to reconcile vrith clinical facts. The symptoms commonly referred to cerebral congestion may be grouped in two classes — those of excitement, and those of depression. Either of these may exist alone; those of excitement may precede those of depression ; or they may partially co-exist. They may be slight or severe ; acute or chronic. In all cases they are increased by the recumbent posture or by depressing the head, by expiration, and by effort ; and they are usually aggravated by constipation, and by in- dulgence in alcohol. In general cerebral hyperaemia, among the symptoms of excitement may be mentioned mental irritability ; headache — slight or violent, with feelings of fulness or throbbing in the head, and vertiginous or other unpleasant sensations ; increased or perverted functions of the organs of special sense, such as flashes of light and noised in the ears ; contraction of the pupils ; sleeplessness, restlessness, startings, twitohings or slight actual convulsions ; and mental excite- ment. The pulse is quick. There may be vomiting. The face varies, participating in the congestions of circulatory origin, and in some of vaso-motor disturbance, such as that which may occur during digestion. In other forms of sup- posed congestion of vaso-motor mechanism, as in those which result from excessive brainwork, the face may be pale, but the nature of these casea is doubtful. Among symptoms of depressed brain-function, are dullness of the special senses ; motor weakness ; mental indifference and slowness; somnolence, especially after meals ; dilatation of the pupils ; and infrequency of the heart's action. Conscious- ness may be lost suddenly, and the loss, it is com- monly believed, may deepen into coma. As a rule there is no fever, but in children the tem perature may be raised a degree or so. In the chronic forms of cerebral congestion, these symptoms, variously grouped and moderate in degree, continue for days, weeks, or months. Their course is marked by great variability. Durand-Fardel has pointed out that in these cases there is often much viscid secretion of the conjunctiva. In the more ooirfe forms of cerebral congestion, the symptoms of muscular spasm, of mental dis- turbance, or of loss of consciousness, may be so predominant as to give a special character to the attack : — In the convulsive form pain or uneasiness in the head commonly precedes the muscular spasm. The latter is usually slight. Consci- ousness may or may not be lost. The delirious form is seen under two aspects — (1) in old age, after emotional excitement; in this the wandering is slight, and often related distinctly to the recumbent posture ; (2 j a much more violent delirium, which is apparently re- lated to cerebral congestion, and is seen some- times after mental work or emotional excite- ment, or after alcoholic poisoning. Occasionally death results. The apoplectic form is marked by sudden loss of consciousness, occurring commonly during effort. The unconsciousness usually lasts only a few minutes, and incomplete general weakness remains for a day or two. In rare cases the loss of consciousness deepens into coma, with ster- torous breathing and relaxed sphincters, and death may occur from the extension of the cerebral depression to the respiratory centres. Vertiginous sensations sometimes give a cha- racter to an attack. In children congestion of the brain is a rare but occasional cause of convulsion or delirium. Headache and contracted pupils make up a group of symptoms resembling meningitis, but fever is rarely present, and if it exists it is slight, and the symptoms usually come on suddenly and pass away in a day or two. Partial hyperasmia leads to localised symptoms of excitement or depression. Local convulsion or paralysis may result. Headache is often intense and localised. If nothing more than congestion is present, the symptoms usually soon pass off. Pathoiosy. — The pathology of cerebral con- gestion is still obscure, since we know little of the relative part played by the blood-vessels and the nerve-elements in determining the symp- toms and their form. An excessive supply of arterial blood is, in all organs, attended with functional activity, and it is easy to unde> stand that active congestion should result in symptoms of excitement. Subsequent depres- sion of function has been accounted for by inferring compression of brain-tissue by eflfused BRAIN, HYPEEiEMIA OF. serum. The reaction of exhaustion may con- tribute. In passive congestion the nerve-tissue is imperfectly supplied -with oxygenated blood, and compressed by distended vessels, and its functions are impaired by the presence of effete products. Hence the predominance of symptoms of depression over those of irritation. DiAQNOsis. — The diagnosis rests on the dis- covery of circulatory and other causes of cerebral congestion ; on the circumstances of posture, effort, &c., under which the symptoms came on ; on the existence of concomitant congestion in other parts supplied by the carotids, as the face (by no means invariable); on the diffusion of the symptoms ; on their speedy disappearance ; and on the absence, in the adult at any rate, of elevation of temperature. The diagnosis of the special forms of cerebral congestion from the diseases which they most resemble is considered mder the head of those diseases. PnoQNOSis. — The prognosis is generally imme- diately favourable, but from a severe attack death may probably occur. The apoplectic form is most dangerous, the convulsive least so. De- generated 'weakened vessels render the imme- diate prognosis lees favourable. After many attacks, permanent nutritive changes in the brain supervene. Tubatmbnt. — The most important elements in the treatment of cerebral congestion are pos- ture, removal of blood, purgation, cold to the head, and warm and stimulating applications to the surface. "Whatever be the cause, it is im- portant to raise the patient's head, so that gra- vitation may impede the flow and aid the return of the blood. By this means alone insomnia from hypersemia may often be prevented. The removal of blood is useful in extreme forms of congestion, ei'iher active or passive, especially in those forms of active congestion in which the face participates. Venesection or leeching may be employed according to the severity of the attack ; in active congestion the blood which is taken should be removed quickly. The relief which in such cases fallows an epistaxis illustrates the value of this method of treatment. It is not advisable in those cases in which, from overao- tion of brain-tissue, or from cold to the surface, dilatation of the cerebral vessels results, while the face remains pale. In all forms of con- gestion, purgation is useful. It removes from the blood some of its serum, and it affords im- mediate relief to the cerebral circulation, by causing an afflux of blood to the capacious in- testinal vessels. In plethoric states diuresis is also most useful, and has succeeded where venesection and purgation failed (Reynolds). Cold to the head is of most value in reflex or secondary dilatation of the cerebral vessels, as after mental work, insolation, fatigue, and some toxsemic states. In the same class of cases, sti- mulation of the peripheral nerves by sinapisms, blisters, &c, applied to the neck, will, by reflex influence, assist in obtaining arterial contraction. Hot applications to the limbs act in part in a similar manner, in part by causing local afflux of blood and thus lessening the tendency to en- cephalic engorgement. They are most useful in uctive congestion. Alcohol and opium must be avoided in all forms of active congestion, but BRAIN, HYPERTROPHY OF. 147 in passive congestion they may be of service. Bromide of potassium is useful in those cases in which the congestion is produced by vaso- motor mechanism, excited either by stimula- tion of brain-tissue or of distant nerves. la passive corgeslion from heart-disease the treat- ment is that of the cardiac condition. All per- sons liable to congestion of the brain should live regularly, avoid hot rooms, and attend care- fully to the stomach and bowels, relieving the latter by frequent moderate purgation. W. R. Go WEBS. BBAIIf, Hypertrophy of. — Hypertrophy of brain is a misnomer. True hypertrophy would consist of increase in number or in size of the nerve-cells, nerve-tubes, connective stroma, and supplying vessels : and there might be expected, as a result of this condition, some manifestation of a higher inteUeetual development. Such a, condition is never found. A so-called hypertro- phied brain is one that is larger and heavjer than normal. On removing the skull-cap, the encephalon seems to expand, so as to render it difficult to aflSx the bone-covering in its place ; the membranes are dry, the sulci have nearly disappeared, and the whole organ appears pale and bloodless. On section there is a sensation of toughness, though less in degree than in a case of general sclerosis. There is no sign of pressure upon the orbital plates, such as is met with in chronic hydrocephalus. The lesion affects only the cerebral hemispheres, espe- cially on the convex surface, and perhaps the posterior lobes in particular. The base of the brain and the cerebellum are unaffected except by pressure. On minute examination, the nerve-cells and nerve-fibres, far from being found augmented iji number or in size, may even be compressed and diminished ; and there is often also some inter- ference with the normal calibre of the vessels. Gintrac, however, records a case in which the calibre of the nerve-tubes was almost double that of the normal. What increase there is affects the white matter of the brain, and this structure is very pale and of an elastic consistence. The real and sole lesion is hyperplasia of the connec- tive tissue. It differs from sclerosis in affecting the cerebral hemispheres more universally than is the case with sclerosis ; and also that in sclerosis there is not only increase of the connective tis- sue, but subsequent retraction, aifd, as a fre- quent consequence of this, an absolute destruction more or less of the nerve-elements of the organ. When the disease is far advanced it may pos- sibly cause absorption of the inner table of the skull, and thus prpduee a roughness or thinning of the bone, or, in extreme cases, even perforation. The sinuses are generally distended with blood. Hypertrophy of smaller portions of the brain is rare : still various cases are on tecord in which under the name of neuromata of the nervous centres, white or grey matter has been found in certain parts of the brain over and above the normal constituents of this organ. Hyperplasia of the pineal gland is closely allied to glioma. It should be distinguished from encysted dropsv of that organ. .aJTioLoay.— Hypertrophy of the brain has been 148 BBAIN, HYPEETEOPHY OF. said to be sometimes seeondar;, and caused by the irritation of morbid growths. This, however, is rare. It is generally primary, and may be a disr ease of intra-uterine life ; but it is generally de> Teloped after birth, especially in rickety children. Some forms of encephalocele, without hydroce- phalus, seem to be due to the growth of com- pact masses of cerebral substance in excess of what is normal. The conditions for the produc- tion of this morbid state are infancy ; bad diet ; repeated congestion of the cerebral vessels, such as might be induced by frequent cough ; and, perhaps, lead- poisoning. Symptoms. — The symptoms of so-called general hypertrophy vary according as the sutures are closed or not. If, from insuifieientocelusionof the sutures, the head expands in proportion to the increase in size of the encephalon, the symptoms may be very slight. Children thus affected show no intellectual hebetude; ■ In them, as long as the abnormality is uncomplicated with local inflam- mation of membranes or with haemorrhages, there may be no headache, no affection of sight, no sensory or nlotor paralysis, and no convulsions. Convulsions, however, are common in cases in which the occlusion of the sutures has prevented expansion of the head proportionate to the in- ternal increase of tissue. In such cases also there is generally more or less motor paralysis, often some anaesthesia of the limbs, headache, vomiting, and mental hebetude — symptoms, in feet, either of marked interference with the intra-cranial circulation, or of irritation from inflammatory complications. The prognosis is always bad, but in rachitic cases the course may be chronic. Tbeatuent. — All treatment seems to be inef- fective in diminishing cerebral hypertrophy. E. LoNQ Fox. BEAIN, LACEEATION OF. congested, but very probably there is nothing about which the most experienced patholugist could feel certain until the microscope is re- sorted to. SYMProus.-^It is not possible, in the proient state of our knowledge, to speak with any cer- tainty of the symptoms of diffuse encephalitis. They will Tary, of course, with the region affected- and disturbance of function, followed by more or less complete loss, wiU be the most frequent oc- currences. Tbeatment. — When the symptoms of ence- phalitis are once recognised, it will usually bo too late for treatment, and measures of preven- tion are those of chief importance. The early use of mercury, beginning in anticipation of, rather than waiting for symptoms, is probably the most important ; and next to it come cold to the head, purgatives, and counter-irritation. Jonathan Hctohimson. BRAIW, Inflammation of. — Stnon. : En- cephalitis. — Encephalitis is a term which ought perhaps to be strictly limited to inflammatory changes in the brain-substance itself, to the exclusion of all forms of meningitis. It may be either diffuse or local, but for our present pur- pose we have chiefly to do with the diffuse form. Local encephalitis will generally result in ab- scess (see Bbaiw, Abscess of) and wiU usually be met with, if we put aside the results of inju- ries, in association either with disease of the ear, with tubercular growths, or with pysemic deposits. It may perhaps be doubted whether the oc- currence of diffuse inflammation of the brain- substance as an acute disease has as yet been proved, excepting as a result of wounds. Even as a traumatic lesion, its special features have by no means been accurately studied. It is, how- ever, highly probable that after penetrating wounds of the brain, its substance may inflame, just as the cellular tissue of a limb may, the inflammatory processes, beginning at the site of the wound and rapidly spreading through a large part of the hemisphere. It is probably in the perivascular spaces that the process chiefly spreads, and it is in these that the microscope will detect the most abundant results. Such a condition of diffuse encephalitis may exist with- out there being any visible changes in the brain. It may perhaps be a little softened or a little BBAIK, Iiaceration of. — In the more strict sense of the word, the brain is but little liable to laceration from injury. Yet, in connec- tion with injuries, such as penetrating wounds of the skull, fractures with great depression of bone, and even with violent concussions, the brain-substance is not unfrequeutly, to some extent, torn. In so soft a structure, however, and under the influence of modes of violence which are usually rather of the nature of blows than of anything likely to cause stretching, we rarely meet with results comparable to laceration of any of the firmer textures of the body. Whenever the brain is 'lacerated' it is also contused, and the contusion often ex- tends widely around the rent, and is by far the more important lesion. In the peripheral parts of the brainrmass this is especially true, and it is of little practical use to speak of lacerations excepting as complications of very severe con- tusions. In the central parts, the crura espe- cially, we meet now and then with a laceration properly so called, and it is not very infrequent to find the trunks of single nerves torn across, The consideration of those forms of laceration which are produced by the effusion of blood from ruptured vessels of size sufficient to supply a stream forcible enough to break up the sur- rounding substance, will be found in the arti- cles Apopijixt, Cekebbal ; and Bbaiw, Hiemor- rhage into. In the case of injuries to the head from falls or blows without perforation, certain definite parts are prone to suffer from contusion and laceration. Usually some slight evidence of injury is found immediately beneath the part of the skuU upon which the blow was received, but byfar the chief bruising will be at the opposite point. If the occiput be struck, the anterior lobes will be conl^used ; and if one parietal eminence, the oiiposite sphenoidal lobe. This law, how- ever, IS greatly modified by the differing con- ditions under which different parts of the brain- mass are placed as regards their surroundings. In the posterior half of the skull the brain-mass 18 bulky, and between i ts hinder lobes and the cere- bellum IS a strong flexible membrane, well calcu- lated to break vibrations gradually, and thus to prevent contusion. Nor are there in these regionfl BKAIN, LACEEATION OF. any strongly marked bony ridges against which the brain might be dashed. These conditions are reversed as regards the anterior lobes and the middle lobes, and the consequence is that whilst severe contusions are often seen in the latter, they are much more rare in the cerebel- lum and posterior two-thirds of the brain- mass. In oases Of compound fracture, with tearing of the dura mater, and deep depression of bone, the brain-substance may, of course, be injured at any part ; but even in respect to this kind of violence the hinder regions of the skull are specially protected. Symptoms. — Weknow enough of surface-lacera- tions of the brain in parts other than the anterior and middle lobes, to be able to assert that, unless the lesion extend very widely or deeply, it does not reveal itself by any special symptoms. If very extensive, weakness of the opposite limbs and side of the face is usually observed. Injury to the anterior lobes, unless extensive, cannot be diag- nosed, but it may be guessed at in a few cases where the sense of smell is lost in one or both nostrils ; for it is very common for the olfsictory bulbs to be damaged at the same time. If the anterior lobes are severely lacerated, the symp- toms will be those of very severe concussion, with the difference that the insensibility is more nearly complete, and that it increa.'^es instead of diminishing as the days pass on. When a sphe- noidal lobe is contused there is usually, accord- ding to the writer's observation, incomplete hemi- plegia of the opposite side, involving sensation as well'as motion, and the face as well as the limbs. From these symptoms the patient may, in the course of months, wholly recover. It is usually the apex of the sphenoidal lobe which is lace- rated, but if the lesion extends higher, and if it occur on the left side, aphasia may be present. In connexion with recent discoveries (Dr. Hughlings Jackson, Dr. Ferrier, and others) as to localised functions, no doubt we shall be able before long to diagnose more accurately as to the precise regions injured. It would, however, as yet be premature to attempt to do so. Teeatmknt, and Fbognosis. — In the treat- ment and prognosis of lacerations and contu- sions of the surface Of the brain, Jnuch depends upon whether or not the case is complicated by compound fracture and the admission of air. If air have been admitted there is risk of menin- gitis or encephalitis, denoted in either case by the occurrence, within a few days of the injury, of hemiplegia of the opposite side. To prevent this must be the object of treatment. The scalp should be shaved, the wound closed with sutures as £i,r as practicable, and lint wetted in a spirit- and-lead lotion should be laid over the part and systematically re-wetted every hour. If the case be treated in ho^ital it may be well, in addition to this, to wash the wound with the lotion before closing it, or to dress with Lister's antiseptic precautions. In cases of laceration without ac- cess of air death may ensue from diffuse softening around the part. If this happens the case will probably end within a week or ten days. It is probable that many cases of fractured base with more or less severe laceration of brain recover ; in S'>mi> with permanent paralysis, but in others without. It must be added that many of the cases BRAIN, MALFORMATIONS OF. 149 in whieh death occurs within a few hours or a day or two after fracture of the base are attended by laceration. In these the symptoms are often difficult to distinguish from those of compression. Profound insensibility, a bloated face, stertorous breathing, and a full pulsey are often present , but they may be substituted by pallor and a feeble pulse in connection with great depression of the heart's action. If any deviation from symmetry £is regards the paralysis of the limbs can be proved, it is in favour of laceration and against compression, but the differential diagnosis is a matter of extreme difficulty. Ijaceration of Cranial Nervea. — Lacera> tions of single nerves within the cranial cavity are not by any iheans uncommon. This occur- rence is to be suspected whenever the parts sup- plied by a cranial nerve are completely paralysed, without accompanying symptoms indicative of severe lesion of the brain-mass. Cases of lace- ration of the brain itself may be complicated by laceration of nerve-trunks, and thus the symptoms may become difficult to interpret with confidence. Of single cranial nerves the olfactory bulbs are the most liable to suffer from contusion ; and the third, fourth, and sixth nerve-trunks are those most frequently torn through. Jonathan Hutchinson. BBAIir, Malformations of. — ^The malfor- mations of the cranium and its contents may be divided into two series : — A. Those which are scarcely compatible with life ; and B. Those in which life is possible, although the intellectual power may be more or less modified from a, healthy condition. A. The Jirst series will include at least seven forms, in all of which life is so rare that it is impossible to speak of more than the pathological anatomy. 1. Sicephalia — in which two heads are found upon a single body, or upon two bodies pretty extensively connected. In the first variety, one head may be attached to the vault of the palate of the other, or may be united to the convexity of the skull. In the second variety the headk may sometimes spring from a single' neck. This dicephalous condition is frequently accom- panied by malformation affecting the spinal column and spinal nerves, as well as by some incompleteness in the development of the brain. 2. Monocephulia — the union of two heads into one, on two separate bodies. The two cranial cavities are united into one. Dissection of the dura mater points to this membrane having been formed out of two, and in like manner the cranial contents are either double, or appear to be single from the union of double organs. 3. Aoejthalia — the complete absence of head. An acephalous monster is usually a twin; and when this is not the case, it is associated with the morbid condition of the uterus of the mother known by the name of uterine hydatids. 4. Paraeephalia — the head not entirely want- ing, but deprived of most of the cranium and of the face. A monster of this kind is generally a twin. 5. Anencephalid. — The absolute meaning of _this term would be the absence of all cranial contents, but it is made to include certain vario- 150 ties, differing according to the amount of the encephalon developed. The aspect of the head, resembling that of a frog, the considerable pro- jection of the eyes, the flattening of the forehead, and the absence of the cranial vault, are the chief characteristics of this abnormality. In the first degree, there is absence of cere- brum, cerebellum, mesocephale, and spinal cord. In cases of this kind the cranial vault is generally absent, and the bones at the base of the skull convex and thickened. In the second degree, the cerebrum, cerebel- lum, and mesocephale are absent, but a portion of the spinal cord is found. This portion of cord is most usually the lower part. In the third degree, the spinal cord is pretty complete, but there is siill an absence of the cerebrum, cerebellum, and mesocephale. A few cases have been recorded of the fourth degree, in which no cerebrum or cerebellum are found, but a normal spinal cord, and a pretty, complete mesocephale. In the fifth degree,the cerebrum alone is entirely or almost entirely absent, whilst the rest of the nervous centres are present, though not always in a perfectly complete condition. The seat of the absent cerebrum is often filled by fluid. Lastly, one case has been recorded in which the cerebrum was present, whilst the cerebellum, mesocephale, and spinal cord were wanting. Anencephalia, like the other previously men- tioned malformations, is due to arrest of develop- ment, such arrest depending either on physical injuries to the uterus at a very early period of pregnancy, or to some mental shock experienced by the mother during the first two months after conception. It diifors from acephalia, not only by the partial formation of the head, but by the presence of the heart, and other thoracic organs. The ganglia of the sympathetic are usually well- deroloped. 6. Pseudencephalia. In this malformation there is anencephedia jplua a very considerable thickening of the meninges, which take the place and often imitate the aspect of the brain. Its varietie.s exactly correspond to those of anen- cephalia. The tumour formed by the develop- ment of the membranes is of variable size and position. It may be frontal, fronto-parietal, or occipital. The real seat of the lesion is the pia mater. The abnormality consists in extreme hypertrophy of this structure, with complete arrest in the development of the encephalon, or of some portion of it. Several observers have recognised certain vesicles in the interior of the membranous tumour, and these have been sup- posed to be cerebral cells in process of develop- ment. It is more in accordance with observation to believe with Gintrac thai they are connecced with the development of the choroid plexus. 7. Cyclocephalia. In this monstrosity there is an approximation or actual fusion of two eyes in a common orbit. It is connected with certain abnormalities in the brain, that militate against viability, or at least prolongation of life.. The brain itself is generally more or less deficient, especially in its anterior and central portions, uud in some cases the nose and mouth are very ill-developed. B. The seccnd series of cases owe their ab- ' BEAIN, MAXFOEMATIONS OF. normal conditions to injury arising in the course of foetal life ; and some forms at least may be due to lesion occurring at a later period than in the first Series. 8. Atelencephalia — incompleteness of brain or of membranes — is the chief of these forms. This incompleteness manifests itself in seven varieties according to the part of the oncephelon injured by the lesion. In the first variety, the dura mater is some- what deficient, being altogether absent in certain situations at the base of the brain. The falx cerebri may be wanting, or from incomplete development it may seem perforated vnth holes ; or the tentorium cerebelli may be absent. There are no symptoms which allow a positive diagnosis of any of these lesions during life. In the second variety, there is general incom- pleteness of the brain, or imperfection of several portions of it at one and the same time. Whilst the cranial vault is thrown back, and the lower jaw is short, the base of the skull is large, the cerebral convolutions almost absent, and the cerebellum large. The head is almost always small, and it may present various irregular forms. This coincides vvith certain internal lesions, partial or general atrophy with conse- quent serous effusion under the membranes, in- flammatory conditions, or thickening of the cranial bones and of the meninges. The incom- pleteness of the brain varies exceedingly, from a condition in which the whole brain is atrophied, to spots of deficiency, such as the absence of a single convolution, of the septum, or of the pineal gland. The symptoms will necessarily vary much according to the amount of cerebral incomplete- ness. 'Where this is general, affecting in some degree all the convolutions, the intellectual powers, as in the microcephalous Aztecs, will be very slightly developed, and their language of the very simplest form. With the brain still more imperfect, there is generally complete idiocy or a condition closely allied to it. The special senses are dulled, particularly sight and hearing. Speech is in abeyance, or is limited to monosyllables. There are various motor pheno- mena, such as muscular debility, hemiplegia, paraplegia, contraction, convulsion, loss of power over sphincters, dysphagia, vomiting, or feeble- ness of respiration. The third variety includes incompleteness of the central parts of the brain. The corpus cal- losum, the septum, the fornix, the corpora striata, and the cornua ammonis may be imperfectly developed. The cerebral hemispheres may thus be in some sort fused togetheir, and the shape of the ventricles altered. The symptoms differ from those of the preceding variety, in that the special senses are seMom involved; and that, although complete idiocy may accompany these lesions, it is more usual for the brain to be found capable of some slight intelligence, though un- equal to the conception of abstract ideas. In the fourth variety, the lateral portions of the brain are incomplete. This lesion generally occupies one side of the brain, leaving the other hemisphere intact. Several points in the hemi- sphere may be affected, or the whole of a single lobe. Most usually there is a depression occupy- ing the seat of one or more convolutioiis. Such BBAIN, MALFORMATIONS OP. ji lesion occasionally attacks the whole homi- Bphere, giving it the appearance of a large pouch filled with fluid. Sometimes also the neighbour- ing ventricle communicates -with it ; o» there may be much ventricular effusion, with imperfect de- velopment of the corpus striatum, the optic thalamus, the cornua ammonis, the mamillary tubercle, the crus cerebri, and the optic and olfactory nerves of one side. In a consider- able proportion of patients so affected, the lesion is accompanied by idiocy, and possibly the inability to speak is connected with this mental condition. Some few patients, how- ever, possessed with some intelligence, have yet been unable to speak ; this has been the case even when the lesion has existed on the right side. Deafness is rare; feebleness of sight, Tarions forms of strabismus, and nystagmus common. Very frequently there is hemiplegia of the side opposite to the lesion, and certain other affections of the limbs, — emaciation, incom- plete development, contraction, various deformi- ties of the hands, &e. Sensation even in the paralysed limbs is normal ; convulsions are not uncommon. In the fifth variety, there is incompleteness of the anterior portion of the brain. Here both the anterior lobes are affected together. This con- dition may be associated with some deficiency of the corpus callosum, fornix, and corpora striata. Idiocy is not uncommon ; mutism is the rule, but in some patients not idiotic a. few words have been possible. Other phenomena — amaurosis, strabL^imus, and various motor abnormalities — have occurred so irregularly in these patients that it is probable they were symptoms not so much of this lesion as of certain further compli- cations. Incompleteness of the cerebellum forms the sixth variety. This is sometimes associated with a similar condition of one side of the brain. Usually one lateral lobe only is affected. Gene- ral hydrocephalus is an occasional complication, and a collection of fluid under the tentorium cerebelli is very common. The symptoms are very negative. In general terms it may be said that there is no loss of muscular co-ordination, and no loss of sexual power. In the seventh variety, there is incompleteness of the mesocephale and medulla oblongata. This is not carried very far. Certain modifications in form and volume are alone compatible with the preservation of life. It is not a common lesion, and has generally been associated with idiocy. 9. Congenital hpdrocephalua. One variety of this congenital effusion of fluid is rare, viz., when the fluid is outside the dura mater, between this membrane and the pericranium, and the cranial bone."! are found floating in the midstof the fluiii. The second variety is that in which the fluid lies outside the brain. The writer believes that serous effusion in this position is not the cause of the atrophy, flattening, or induration of the subjacent cerebral organs, but the effect ; that where fluid is found in this situation it is only the consequence of some one of the lesions al- ready mentioned, notably atrophy of brain from whatever cause, and of atelencephalia. This view is, however, opposed to that of some authors. BEAIK. (EDEMA OF. 131 The third variety is congenital hydrocephalus of the ventricles. In some such cases the in- crease in the size of the head occurs before birth ; in others, not until after. The head increases rapidly in size in the flrst four weeks aftpr birth. The sutures are widely separated, the cranial bones very thin, the integuments of the head injected, and the hair deficient. The muscles are badly developed, locomotion is imperfect, the intellect is generally obtuse, but the special senses are not particularly affected, unless it be that sight is deficient. 10. Synmcephaliaia merely a matter of patho- logical interest. The head of the foetus is some- times found adherent to the membranes or to the placenta, as a consequence of intra-uterine inflam- mation. At the point of adhesion the place of the cranial bone is taken by a thin vascular mem- ' brane. This condition is sometimes accompanied by, and indeed perhaps causes, encephalocele, 11. Exencephalia. — Here a large portion of the brain is situated outside the cavity of the cra- nium. Practically it includes all the other mal- formations of the brain that are yet to be spoken of. Thus, if only a limited portion of the brain finds its way outside the skull by an abnormal opening, the displacement is known by the name of encephalocele, or hernia cerebri ; if this hernia coincide with a hydrocephalic condition of the ventricles, it is called hydrencephalocele ; and if the hernia is composed not of the brain, but of the membranes, distended with fluid it may bo, the lesion is called meningocele or hydromeningo- cele. Exencephalia proper may be subdivided inUi frontai, mncipifits branches, suffers twice as frequently on the left side as on tho right. There may be more than one aneu- rism, situated on different arteries or on different branches of the same artery. The aneurism is usually sacculated, rarely dissecting. Its sizo varies from 'that of a pea to that of a nut, but aneurisms of the anterior or middle cere- brals have atta,ined a niuch larger size. When this is the case the brain-tissue is pressed upon and softened. MnoiX)<3Y AND Pathology. — These aneu- risms are rather more common in men than in women. They occur at- all ages, being more fre- quent before the ordinary degenerative period than aneurisms elsewhere. Nearly half the re- corded instances have occurred between ten and forty years, and about one-seventh between ten and twenty. The change in the arterial wall resembles tlislt giving rise to aneurism elsewhere ^a fibroid degeneration, with loss of muscular and elastic tissue. This may be part of a widely spread arterial change, or more frequently is local.. When local, it is sometimes due to syphi- litic disease of the arterial wall, but still more frequently to the consequences of embolism. Dr. Church first'pointed out the frequent asso- ciation in young persons of cerebral aneurism and valvutor distease of the heart, and many facts have been published which support the hypothesis that the aneurism in these cases may be ths consequence of incomplete obstruction by embolism. There is often evidence of inflammatory and degenerative changes (thickening, calcification) in the artoria] 162 BRAIN, VESSELS wall after embolism, especially -when the plug cqmes from an inflamed endocardium. If the obstruction is incomplete, the altered -wall may yield to the blood-pressure. In harmony with this theory are the fMquent absence of degene- ration in other arteries, the frequency -with which the left middle cerebral is the seat of the aneu- rism, and the occasional occurrence of several aneurisms on branches of the same arterial trunk. The efficient agent in the production of the aneurism is the high blood-pressure in the cere- bral arteries. Buptm-e has occurred in about three-fourths of the recoided cases of cerebral aneurism. The blood may escape rapidly or slowly, and the haemorrhage may take place into the subarach- noid space, or into the adjacent cerebral substance. In the former case, meningeal haemorrhage is the result. Kupture into the cerebral substance is not uncommon. An aneurism in the fissure of Sylvius may cause a haemorrhage into the substance of the brain, bursting into the lateral ventricle; and an aneurism on the posterior cerebral artery may burst into the substance of the pons. Two causes may determine this rupture into the substance of the brain — first, thickening of the subarachnoid tissue adjacent to the aneurism, hindering its rupture outwards ; secondly, the gradual escape of the blood, producing a slow disintegration of the brain-tissue, and thus preparing a channel for the effusion. In such cases only a small quantity of blood may have tricMed into the ventricles or subarachnoid space. In rare eases a commimication with a sinus forms, and constitutes an arterio-venous aneurism. This has occurred between an aneur- ism of the internal carotid and the cavernous sinus. SYMPTOMS. — Symptoms of the existence of an aneurism may be entirely absent. When present they depend on the pressure which the tumour exerts on neighbouring parts. They vary widely according to its seat, and they are rarely by themselves distinctive. Mental disturbance is uncommon. Headache is averyuniform symptom. It is often intense, sometimes throbbing, and may be localised, as in the occiput in basilar aneurism. Convulsions occur in some cases, and are said to be more common when the disease is near the medulla. Paralyses are frequent, and depend on the pressure of the tumour : the most common are those of the cranial nerves which lie adjacent to the aneurism, as of the nerves of the orbit in aneurisni of the internal carotid. Such symptoms are suggestive of an aneurism when they indicate pressure in the known situation of a vessel. In some cases a murmur can be heard by the patient, and in still rarer cases (of aneu- rism of the internal carotid) it has been ■audible on auscultation. Aneurism elsewhere may increase the probability that an intracranial aneurism is present, and so, in the young, may valvular disease of the heart. Bupture of cerebral aneurism gives rise to symptoms which vary, as in rupture of aneurisms elsewhere, according as the blood escapes qoiiclcly or slowly. If quickly, the blood usually escapes into the meninges and causes sudden apoplexy with general paralysis, rapidly d^epen- OF, DISEASES OFi ing to a fatal issue. If slowly, the symptoms are less sudden, and unilateral paralysis or con- vulsion may occur. This is especially thecase when the blood escapes slowly into the cerebral substance, unilateral symptoms occurring, and gradually increasing during a few houra or days, with or without initial loss of consciousness, but ending in fatal coma. Teeatment. — Little can be done in cages where intracranial aneurism is suspected. Even when it is of syphilitic origin, drugs can only partially restore the damaged and dilated vessel, Hypodermic injection of ergotin (|-grain) has been recommended by Langenbeek and advo- cated by Bartholow. Iodide of potasisium may also be given. Kest is important. All causes of increased intravascular pressure, sucli as effort and low positions of the head, are to be avoided. The bowels should be kept regular. In rare cases where progressive paralysis of orbital nerves suggests the probahility of aneurism of the in- ternal carotid, and a murmur renders the diag- nosis certain, ligature of the common carotid may be, and has been, resorted to with success. (4) Minute ' miliary ' aneurisms occur in the small arteries of the pia mater and substance of the brain (Virchow, Charcot and Bouchard). They are found at .all ages, but more fre- quently in the old. They may involve vessels not more than the -^ inch in diameter, but are most common on vessels a little larger than this; the walls suffer fibroid degeneration of the outer and middle coat, commencing, it is said, as nuclear proliferation. The muscular tissue of the middle coat disappears, and the whole wall at the spot becomes dilated into a sacculated aneurisih, varying in size from the i to the -jjj of an inch. These dilatations have been found in all parts, but most frequently in the optic thalamus, and next most frequently in the pons Varolii, the convolutions, the corpora striata, the cerebellum, the medulla oblongata, the cerebellar peduncles, and the centrum ovale (Bouchard). They often rupture and cause minute haemorrhage. They are found fre- quently in cases of large cerebral haemorrhage ; and Charcot and Bouchard believe that such haemorrhage is frequently due to their rupture. Liouville has pointed out that minute aneu- risms of the retinal arteries sometimes co- exist. The rupture of a minute artery into its peri- vascular sheath distends it with blood, causing what has been termed a minute dissecting aneu- rism. Such are frequently met with in' cases in which the vessels are exposed to extreme pres- sure, as in death from asphyxial conditions ; or in the increased tension in' collateral vessels when vascular obstruction has occurred. No SYMPTOMS are known to be associated with the existence of these minute aneurisms. The symptoms of rupture are described under ' Brain, Haemorrhage into.' 2. Degeneration, (a) Of Arteries. — The larger cerebral arteries are vety common seats of the thickening of the inner coat, called by Virchow ' Endarteritis deformans,' and: whicli, when fattily degenerated, constitutes 'atheroma.' On the cerebral vessels the fatty change occurs quickly and frequently; and opaque' veUoW BEAIN, VESSELS Oi", DISEASES OF. iMckenings are the result. Only- one or two of these may be present; or the liange may in- volve the whole of the larger Tessds at the base and extend for a ooneiderable distance along the chief cerebral branches. The dis- tribution of the degeneration may be symme- trical. It may coexist with a similar change in arteries elsewhere, or may be isolated. De- generation of the cerebral arteries is com- mon after middle life, being found in seren- tenths of the subjects examined (Bichat). It occasionally occurs much earlier, especially in eases of chronic Bright's disease. Bright's dis- ease and alcoholism are its chief diathetic pre- disponents. The exciting cause of this disease is probably the strain to winch the badly supported cerebral vessels are exposed. It is not easy to explain their occasional freedom from atheroma when this is abundant elsewhere. The degene- rated patches rarely soften and open into the vessel, BO as to permit the formation of a dis- secting aneurism. More commonly they undeiv go calcification. The result of these, nodular degenerations is to lessen the calibre of the vessel, sometimes to close it altogether, and to favour the formation of a coagulum. The les- sened area of the vessel causes local aneemia of the brain. If the vessel becomes occluded, or if coagulation takes place in it, softening occurs in the part supplied by it. Where the degeneration has led to Only slight thickening of the wall, the artery may be dilated at the spot. The degene- rated vessel may burst under the pressure of the blood and hasmorrhage result. The minute arteries of the cerebral substance undergo simi- lar changes, less conspicuous from their smaller size. Fatty degeneration of the cells lining the perivascular sheath is common at all ages. Under circumstances similar to those in which the larger arteries degenerate, all the coats of the small vessels suffer. Simple fatty degene- ration of the middle coat occurs also at all ages. Miliary aneurisms may be formed, or rupture occur, aa a consequence of these changes. Symptoms.^- Atheroma of the cerebral vessels leads to the symptoms of local anaemia of the brain, and is a common cause of the transient cerebral symptoms so firequent in the old. Treatment. — ^Tonics, cardiac stimulants, and substances which, as cod-liver oil, promote the nutrition of the nerve-tissue, are the most useful remedies. (6) Of Veins. — Degeneration of the walls of the veins is much less frequently observed than degeneration of the arteries, perhaps on ac- count of the less degree of pressure to which they are exposed. Occasionally the veins of the pia mater may be found varicose in advanced life, and in one ease recorded by Andral rupture of such a dilated vein was the cause of menin- geal hsemorrhage. 3. Smboliam. — DEFnnTioN. — The obstruc- tion of arteries or capillaries of the brain by solid particles carried by the blood-c^aent from some other part of the vascular system. ■ .SItiolooy. — The source of the embolic par- ticles is almost invariably situated between the -pulmonary capillaries and the obstructed vessels, i.e. in the, pulmonary veins, the left side of the heart, or the arteries. In arterial embolism it is 163 necessarily sov since no particles large enough to obstruct even a small artery could pass through the capillaries of the. lungs. In almost all cases the heart is the source of the plugs, a particle of fibrin being washed by the blood from a deposit on a diseased valve or in some recess (as the auricular appendix). Endocarditis, or chronic valvular disease, therefore, usually coexists with the embolism. Mitral stenosis is an especially frequent source of emboli, probably because the surface is commonly much altered, and the blood- current is in part slow (in diastole, allowing deposit), and in part very rapid (in auricular systole, detaching loose fibrin). Disease of the aorta — atheroma or aneurism — ^is the next most frequent source, and, less frequently, disease of the carotid or vertebral arteries, and coagulation in the pulmonary veins, large or small — the latter in some rare cases of inflammation and growths. Particles obstructing capillaries may come from some softened atheromatous patch or fibri- nous deposit, from pigmentary formations, or from deposits in ulcerative endocarditis. In the last case the obstructing material has a septic character, and the inflammation it causes may be suppurative. Anatomicat, Characteeb. — Almost any of the cerebral arteries may be obstructed, the internal carotids and middle cerebrals or their brandies most frequently, the anterior cerebrals or the basilar less frequently, and the posterior cere- brals still less frequently. Obstruction of several vessels is sometimes found, having occurred at the same or at different times. The cerebral arteries of the two sides are plugged with nearly equal frequency ; the internal carotid much more frequently on the left side than on the right. It seems that a large fragnient is influenced in its course by the more direct path through the left carotid, while smaller fragments find their way with almost equal readiness to either side. The middle cerebrals are' very frequently affected, sometimes on both sides ; and, when the bilateral symmetry of the vessels is great, each may be obstructed at the same place. The jilug is usually arrested at some spot at which the vessel is narrowed by a branch being given off. Here the fragment may be found, usually decolorised, and commonly closing alto- gether the lumen of the vessel. On each side of this is a secondary clot : the distal extends far into the contracted branches of the vessel, the proximal as far as the next large branch. The obstruction may lead to inflammation of the wall of the vessel at the spot, especially when the plug has been carried from a place at which inflammation is going on. The inflammation leads to change of texture and degeneration, fibroid or fatty; the former may permit an aneurism to be formed, the latter may cause a thickened patch, in which calcification may occur. • The inflammation may spread to the adjacent tissue, leading to induration around tht spot. The first effect of embolism is to arrest the blood-supply to the part to which the artery is distributed. It is only when the obstruction is beyond the circle of Willis that damage to cere- bral structure (softening) follows. Softening 164 occurs more uniformly in obstruction of the arteries of the central ganglia than in those of the conTolutions. Capillary embolism also causes softening, alnd when the obstruction is from a septic source, ' metastatic abscess ' may result. For the stmftoms, diaonosis, and tbeatueiti of cerebral embolism see Bbain, Softening of. i. Bupture.^— Rupture of oernbral arteries is common and is the cause of cerebral haemor- rhage, and rupture of capillaries is not unfre- queat. Eupture of veiiis is extremely rare, ex- cept as the result of injury. (a) Of Arteries. — The ' proximate causes of rupture are -weakening of the arterial wall, and increased pressure 'within the ressel. The con- ditions -which give rise to these two factors are the remote causes of rupture. The actual rapture is commonly due to a temporary sttdd^n excess of intra-yasoular pressure. ^TioLOSY. — ^The -wall of the vessel is weak- ened, especially by degenerative diseased-chronic periaffteritis, or (rarely) simple fatty degene- ration. Aneurismal dilatation and thinning may have resulted from the chronic change, i In some diseases attended -with a tendency to extra- vasation (purpura, haemophilia, &c.) it is conjec- tured that the vascular wall's have undergone rapid degeneration, or are imusually thin. De- fective external support; from atrophy- of the brain, causing increased size of the perivascular canals, was formerly thought to be a potent cause, and is now perhaps underrated. The mobile perivascular fluid which surrounds the vessels vmat afiord a less efficient support than cerebral tissue. When vessels are much weakened, they may rapture when the extravascular pressure is at, or even below, the normal ; very commonly, ho-weveis, there coexists increased pressure. Loss of arterial elasticity leads to a jerky pressure! Arterial degeneration, and still more constantly, arterial contraction, in Bright's disease, cause increased tension by obstruction ; and^ the hypertrophy of the 'heart, which develops to overcome the obstruction, adds materially to the pressure within the arteries. ■ H^ertrophy to overcome an obstacle near the heart has pro- bably no influence in causing rupture of cerebral BEAIN, VESSEXS OF, DISEASES OF. The instant cause of rupture is generally some temporary increase of the blood'^pressure'due to effbrt — as in cough, straining at stool or vomit- ing ; excited action of the heart ; suddenly de- veloped heart- or Inng-disease obstructing the circulation ; local obstruction to return of blood ; contraction of the arterioles, general or local ; or the action of gra/vitation in the recumbent pos- ture. The last two causes probably acting to- gether determine the frequent occurrence of rupture during sleep. The conditions which produce these proximate causes are the remote causes of rupture. The most efficient are those which determine weaken- ing of the vascular wall, and have been already spoken of (see Dboen:eeation). Age is an im- portant element — rupture is most common after fifty, but may occur from local vascular disease at any age. Hereditary precUsposition is seen in a tendency to early degeneration. Position of degeneration is probably largely influenced by the distribution of the vessels : and the latta may be strikingly hereditary, a^ the retina some- times shows. Sex tells probably 'by exposure to the greater pressure entailed by muscular effiirt (men suffer from rupture t'wice as frequently as women). Alcoholism leads to early degeneration. But the most efficient predisponent is Bright's disease, which leads to great intravascular pres- sure, and weakens the cerebral vessels, by causing degeneration. It is probable that some acute diathetic diseases in which rupture is common act in a similar manner. Certain of the cerebral arteries give way more frequently than others, especially the arteries of the corpus striatum, and pons Varolii.!,, This seems due (1) to their origin at right anglesfrom vessels of very considerable size (basilar: and middle cerebral), and their consequent exposure to the' full pressure within the parent trunk. (2) To their 'terminal' character, which precludes collateral relief (Duret, Heubner). One artery, which very frequently gives way, passes from the middle cerebral . through the anterior perforated spot, . outwards be- tween the ' island of Eeil and the lenticular nucleus; the outer part of which it perforates, and then passes through the white ' internal capsule,' between the lenticular and. caudate nuclei, to ramify in the anterior part of the latter. The arterioles, supplying, the, con- volutions on the surface of the braia are not often ruptured, .except from injury. They are exposed much less directly to the blood-pressure, and sometimes possess considerable anastomoses. Symptoms. — The consequence of rupture of an artery is cerebral haemorrhage, the symptoms and treatment of which are described elsewhere .(^see Brain, Haemorrhage, into). ^ In traumatic laceration of the brain the arteries, are torn, and often cause much haemuirhage. (J) Of Capillaries. — The minutest arteries and veins and . the capillaries rarely rupture, except when exposed to sudden pressure by venous thrombosis, when the obstruction in the part from which the vein proceeds may deterpune numerous capillary haemorrhages into thp cere- bral substance. In general venous congestion, as in asphyxial states, such, haemprrhage, may occur ; but a more frequent result is, rupture of a 'vessel 'within its perivascular shea,th,wliich thus ibecomes distended with blood, , ,. For SYMPTOMS see BnAiN, Haemorrhage into. 5. Syphilitio Disease. — . The arteripsi of the brain are .occasionally diseased jn the later stages of syphilis. The large arteries at the base and the minute arterioles may; be, both invojved. The wall is thickened at circumscribed lareas by a fibro-nuclear growth, which causes a noflulai projection on the exterior, and diminishes also the calibre of the vessel. The structure of the growth resembles that of syphilomata elsewhere. It is said by Heubner to begin by a nuclear pro- liferation between the inner coat and the elastic lamina ;; and in (some cases it attains, its chiei deyelopijient in this situatipuj the elastic lamina -b^g pushed outwards and the lumen of the ves- ■ sel obliterated. The middle coat may ultimately disappear. Vessels may form, in the substance of the growth, and its centre may undergo fatty degeneration. , The disease is sometimes sym- BEAIN, VESSELS OF, DISEASES OF. 165 cietrical on the arteries of the t-wo sides. The growth or secondary thrombosis occluding the vessel,' softening may result in the area of brain- tissue supplied by it. The softening resembles in its occurrence and characters that whioh is produced by degenerative changes in the ar- teries, but is more varied in its seat, and it affects younger persons. The diminished elae- tiaity of the diseased wall, -when' the thickening is slight, may permit the dilatation of the vessel into an aneurism. Possibly the same result may follow the fatty degeneration of the new tissue. SiMPTOMS. — No symptoms are produced by the arterial disease until it causes local anaemia or softening, the symptoms of which resemble those due to other causes. Thbatmbnt.— This is that of the later stages of syphilis. It must be remembered that the removal of arterial disease may not restore the damaged cerebral tissue. 6i ' Thrombosis. Thrombosis, — the coagula- tion of the blood msitu, — ^may occur in the cere- bral arteries ;■ or in the cerebral veins and sinuses. (0) In the Arteries. JEnoT.ootY'. — The causes of arterial, thiom- Dosis are the following : — (1) An alteration in the wall of the artery, by which the blood comes in contact with an abnor- mal surface. The most common condition is athe- roma, and hence arterial thrombosis is most frequentwhen atheroma is most common — in the 61d.- SyjlMlitic diseaae of the artery sometimes leads to it. = Much more rarely it is caused by an arteritis, spontaneous, or the result of ad- jacent inflammation or traumatic damage. ' (2) Eetardation of the blood-current. This May result from weakened action of the heart in debilitating diseases (as phthisis and cancer), and in extreme fatigue. It may be part of the effect of a convulsive fit; or it maybe caused locally by the arterial diseases mentioned al- ready, which lead to narrowing and loss of elasticity. (3) An increased tendency of the blood to coagnl'at^. This is seen in many diseases, espe- cially in marasmic states in young and old (such as are caused by phthisis and cancer), in acute irheumatism, and in the puerperal con&ion. A slight cause then suffices to produce coagulation, and the weak heart, so common in many of these conditions, may cause sufficient retardation of the blood-current. (4) Lastly, thrombosis in an artery :ma-y be secondary to its complete or partial-obstmotioh by an embolus. Anatomical Chaeaotbks. — The arteries oc- diided may be one or several, and large or small. Of large arteries the basilar,' middle cerebralj and carotid are those occluded most commonly, and with nearly equal frequency. The vascular wall may present any of the local causative con- ditions, or may be healthy. After a time thickening from secondary arteritis occurs. Within this vessel is a coaguluin. which usually fills its interior, and is -adherent to the wall. It may not fill 'the vessel, either because origi- nally imperfect, or because the clot has shrunk. A recent quickly-formed coagulum is red, but after a time it becomes pale and yellow. A slowly^formed coagul'om is pale, and may be> laminated. A secondary clot usually forms far into the contracted distal branches, and on the proximal side as far as the nearest large bra,uch. Ultimately the clot may, rarely, soften, the channel being sometimes re-established. More commonly it undergoes calcification, or, with the artery, contracts and becomes atrophied. The brain-tissue, in which th6 artery was distributed, may be at first ansemio, but quickly becomes congested. It ultimately undergoes softening — red, yellow, or white, according to the amount of vascular distension. If the collateral circu- lation, is free-it may remain unsoftened. . • ' Symptoms. — ^Where chronic arterial' disease is the cause of thrombosis, the symptoms of local cerebral ansemia, may precede {see Bbain, Anaemia of). The thrombosis itself leads to the symptoms of loss of function in the part to which the artery passed. The onset of these symptoms is slow or sudden, according to the rapidity with which the coagulum forms ; and their degree depends on the sizeofthe vessel occluded, its position, and its relation tp other vessels which may supply blood to the, area involved. Throm- bosis of a small vessel in_ the cerebral substance lisually, leads to transient brain-disturbance, headache, vertigo, tingling, and temporary weak- ness in the limbs, which soon pass away if a, col- lateral- circulation is establisjied ; more slowly, if softening ensues, by compensatory action else- where. The ocdttsion of' a large vessel causes commonly more marked symptoms. Complete hemiplegia is frequent, and its onset ipay be, marked by loss of consciousness {see Beain, Soft- ening of). DuoNOSis. — Diagnosis rests on a combination of the symptoms of local cerebral disease with the causal: condition^vascular .mischief (indicated by probable age, degeneration elsewhere, or syphilis), and with conditions leading to relaxa- tion of the blood-current, or increased coagula- bility of the' blood. The diagnosis . is . rendered more proba,ble by the symptoms if slight being transient, if severe being of gradual onset, and, whether slight or severe, being preceded by the premonitory indications of local cerebral anaemia. The PBOGNOSis and treatment of thrombosis in arteries are considered under its consequence, Bbain, Softening of. (A) In Cerebral Veins and Sinuses. Mtiolohy. — Throjjibosis in sinuses may be primary, and due to changes in the. constitution or the circulation of the blood ; or secondary, and due to local causes inducing coagulation directly at the spot affected. The same conditions of retarded circulation and altered blood-state which permit coagulation in arteries, favour it also in veins, and it is often seen in such condi- tions as phthisis and cancer, and especially in marasmic states in children. Local retardation of the circulation from narrowing, of the sinus, or compression of the jugulai vein, occasionally as- sist.s. Local change causing coagulation is usually the extension to the sinus of adjacent inflam- mation,- or of a clqt produced in: a tributary vein by such inflammation. Caries of thp boneg of the skull, especially of the temporal bone, and meningitis are common causes. Inflammation ontside the skull, in the scalp, neck, or face, hai 166 BEAIN, VESSELS OF. led, by means of venous connections, to intra- cranial thrombosis. Lastly, injuries of the skull involving the sinuses sometimes cause coagulation in them. Anatomical Chabactees. — Of primary throm- bosis the superior longitudinal sinus is the most common seat, and thence the clot spreads into the veins on either side, and often also into the lateral sinuses. When secondary, the thrombosis occurs in the sinus nearest to the local mischief; in disease of the petrous bone, the lateral sinus is usually involved. The sinus is distended by firm clot, commonly (not invariably) adherent, sometimes in concentric layers. The -walls of the vessel are healthy Tphen the thrombosis is pri- mary or secondary by extension of clot, but thickened and brittle when invaded directly by adjacent inflammation. After a time the clot may soften and break down. The consequence of venous thrombosis is local arrest of the blood-current, the tributary veins and capillaries becoming enormously disten- ded with blood and rupturing, and the cerebral substance being crammed with minute capillary extravasations which often coalesce. The condi- tion is frequently seen in the convolutions. Blood is also effiised into the meshes of the pia mater, and into the subarachnoid space. Into the looser tissues and into the ventricles serum may escape. Thrombosis of the veins of Galen is one cause of ventricular effusion. Ultimately the brain- tissue, the seat of the isohsemic congestion, un- dergoes softening, first red, and then yellow or white. Occasionally the softening of the clot leads to pyaemia. Symptoms. — The symptoms are at first those of mental excitement, namely, intense headache and muscular spasm, shown as contractions in the limbs, or as convulsion, often beginning locally, according to the position of the conges- tion. These symptoms, after one or several days, are succeeded by those of depression ; with ■coma, and dilatation of pupils. The coma may come on suddenly, and the first stage may be little marked. Convulsions, when present, often continue till death. When the superior longitudinal sinus is plugged, epistaxis, oedema of the forehead, and exophthalmos have some- times been observed. When the lateral sinus is obstructed, there may be painful oedema behind the ear, and the jugular vein on that side has been noticed to be less fall than on the other. DiAONOSis. — ^The diagnosis rests on the oc- currence of severe cerebral symptoms in as- sociation with a causal condition, constitutional or local. Peoqnosis. — This is always serious, death being, in most cases, speedy. Tkeatment. — The indications for treatment are mostly causal. In primary thrombosis stimu- lants and nutritious diet are necessary, and tonics if they can be taken. In secondary throm- bosis, occurring in robust individuals, leeching or cupping is recommended ; purgatives should be given ; and, in the less severe qases, a blister may be applied to the neck, and the utmost care taken to afford free exit for pent-up inflamma- tory products. Pain and convulsion are relieved moat effectually by cold to the head. W. B. GOWEKS. BREAST, DISEASES OF. BBAIN-FEVEB. A name popularly ap- plied to any kind of febrile state in which syap. toms of cerebrsil excitement are prominent; as well as to cases of inflammatory disease of the brain or its membranes. BEEAK-BONE FEVEK. A synonym for Dengue. See Dimavis. BBEAST, Diseases of. — This subject will be treated under the following divisions : — I. Diseases before puberty/,, in both sexes. II. Diseases about, the age of the establishment oj puberty ; and after that period, in the female, — (A), in the active state of the gland ; (B), in the passive state. lU. Diseases affecting the rudi- mentary organ in the male. IV. Diseases of the nipple. The diseases of an organ composed essen- tially of glandular structures have here to be described. The mammary gland is classed with those termed racemose; but it differs from every other organ in the body of a similar class, inasmuch as it only arrives at maturity when its function is to be subservient to the nourishment of the offspring. In its perfection it appears, normally, only in the female sex, and even then it does not become developed until the internal organs of generation are capable of peribrming their functions. Hence, to describe systematically the diseases of the breast, it is requisite to treat of them not only in reference to sex, but also in relation to the different periods of life at which certain dis- eases appear. Briefly then, from a histological point of view, they occur : {a) in therudimentaiy state of the gland ; (6) in its mature state ; (c) when it has become a secreting organ ; (d) during a state of degeneration. I. In the rvMmeiitary period of the gland the tissues composing it are rarely liable to morbid derangement. Usually, soon afterbirth, especially in male infants, the rudimentary nipple and the skin of the region within the zone of the areola become slightly elevated and of a pink hue. In some infants a secretion, slightly milk;like, oozes from the ducts. In this state, the injudicious rubbicg practised by the attendant excites inflammation, which, if not arrested by desistance from that pernicious interference, may advance to suppuration. When that happens, the usual local application of warmth and moisture suffices to give relief. II. About that age, in both sexes, when the development of the generative organs advances with greater rapidity to maturity than in early life, the breast-gland enlarges, and may be painful, thus causing anxiety to the individual. Usually, symmetrical development takes place in the female ; but, when the gland of one side takes precedence of that on the other, the circumstance need only be regarded as a departure from the ordinary rule, for no trouble will result, and in due time both will attain their normal pro- portions. In the male, pain or uneasiness some- times occurs for a few days about this period, very often excited by the pressure of the dress. The removal of this cause is sufficient to arrest further mischief. In the female the development of the breast having reached maturity, the gland is now aswi- BREAST, DISEASES OF. 11J7 dated by sympathetic influences commnuiGated through nervous stimuli -with the functions of the pelvic generative organs. This physiological fact should ever be remembered when investi- gating the nature of the morbid affections of this organ. In a clinical point of view, it is essential to examine the diseases of the breast under the tvro states before mentioned, namely, (A) whilst the gland is undergoing metamorphosis into a secreting organ, and during lactatipn. (B) As a mature gland, but passive as regards its function, (glancing at the various morbid states of the body of the gland as a whole, they may be di- vided, primarily, into two groups : — the Ftmo- iional derangements ; and the Organic or histo- logical diseases. We will now proceed to discuss these affections, as they are presented at the diifferent periods mentioned above. A. After conception the breasts soon begin to enlarge, and at their borders and surface minute pisifojrm indurations may be felt. Occasionally, but very rarely, this normal, increase jri bulk is attended with considerable pain and, irritation, extending throughout the nervous relations of the. gland. The pain is referred to the back, neck, inside of arms, shoulders, and side of thorax, over, in fact, the area of distribution of those filaments which pass off to the skin from the same dorsal branches of the spinal nerves, the intercostals which send filaments to the breasts. It affords a good example of reflected irritation. This state usually occurs after the first conception, and in women of excitable, nervous temperament. Attention to ordinary hygienic measures during the progress of the metamor- phosis of the organ into a secreting gland, with its apcomplishment, affords relief to the pain. In large, lax, pendulous breasts, the separate lobes of which each is composed may excite apprehension of the existence of a tumour. But tumours composed of new tissue are so extremely rarely developed during pregnancy, that the greatest caution must be exercised in the diagnosis of their nature. Very rarely, no change whatever iu the breasts accompanies pregnancy, under which circumstances there is an absence of the secre- tion of milk after parturition — Agalactia. Inflammation of the Breast. — Mastitis. iGxioLaoT. — Before lactation, inflammation of the breasts is very uncommon. Afterwards, on the contrary, it is very frequent. This morbid state is often the result of carelessness or ignorance on the part of the nurse. The slightest unusual fulness or 'knottiness' discovered after the infant has been sucking, and when the ducts and their terminal secreting vesicles should be empty, requires immediate attention. Conges- tion of a lobule or lobe with milk produces the nodule, and the cause of the impediment to its escape should be sought for. The state of the nipple is generally the cause of the difficulty. Either the orifice of a duct may be obstructed by epithelium, or a superficial ulceration around ane exists. The morbid qr defective states of the nipple are the most fruitful causes of in- flammation and its results in the breast. Pro- phylactic measures should always be instituted when thsre is reason to fear that a defective development of the nipple will interfere with the free flow of the milk. Even with some mothers it would be advisable to resign the duty of suckling, rather than subject themselves to the almost certain misery arising from per- sistent and ineffectual attempts to do so. In- flammation, generally passing on to suppuration and abscess, either within the body of the breast or on its surface, is most frequent in primipara, and within the first month after parturition. Symptoms. — First, hardness is felt, ' a knot,' in some part of the substance of the organ ; this enlarges, and may attain to considerable dimen- sions before causing pain or even uneasiness. Next, pain is felt during suckling ; this increases each time the infant sucks, and ' the draught ' is produced. The integuments then become pink, and afterwards red, tense, shining ; more or less of the breast feeling very inelastic, ferm, prominent, and heavy. Pain is now often very severe, and great constitutional disturbance is excited. In the centre of the redness the skin becomes of a purplish tint, around this it . is (edematous, and with the finger,. at the centre of the purple zone, a slight depression and softening spot can be detected. An abscess now exists, and in pro- portion to the quantity of pus fluctuation is more or less marked. At the purple centre the cuticle has probably by this time separated from the cutis, and a vesicle containing serum, either yellow or slightly tinged with blood, indicates that ulceration of the cutis is proceeding, and that the pus will soon escape. The above is a brief description of the object;ive signs indicar ting the morbid processes noticeable in all cases of local inflammation advancing to and ter- minating in suppuration and abscess. It is not possible to state with any degree of exactness the period of time required for the accomplish- ment of these definite changes. It varies accord- ing to so many local and constitutional circum- stances, that it would be idle to attempt to pre- dict any certain definite period or stage for each phase. It will be more useful to describe the treatment by which the progress of the disease may be arrested or limited and its painful course mitigated. Tbeatment. — Great attention should always bo given to the nipple of primiparae. In many women, this important division of the gland is very small and undeveloped, perhaps only on one side, so that the infant, especially if not very strong, has great difficulty in obtaining sufficient milk to appease the appetite, and its efforts cause pain in the part. This circumstance induces the mother to prefer suckling most with that breast the, nipple of which is perfect, and the infant soon appreciates the advantages of that side. Consequently the gland-tissue of that breast having the imperfect nipple becomes congested. Every time the infant sucks it becomes worse, more and more pain and irritation are excited, the orifices of one or more of the duets in the nipple become blocked, and perhaps the infant refuses to suck the breast. But the gland becomes more and more distended, the nipple deeply buried, until at last suckling is impracticable. Probably none of these increas- ing troubles have been stated to the attendant surgeon ; and, when he is consulted, he finds tho 168 BEEAST, DISEASES OF. breast to be in the state above descrited. ' The perfect development of the nipple should be always a subject of anxious solicitude on thepart of the obstetric praictitioner. If that organ be Imperfect, precautions 'should betaken to prevent the gland itself from becoming congested, and if the infant cannot draw the nult sfOfficielitly, some mechanical means should be employed to effect this object. The nipple itself should be care- ftiHy examined. If its end be more than usually coated with a white secretion, or the openings of the dnots seem to be obstructed with an excess of epithelium, attempts may be mkde to remove it. If minute abrasions, ulcers, ' cracks or chaps,' are visible between the rugae, some soothing kp- plication should be used. Frequent ablution with warm water, even the contact of a little mOist cotton fibre covered with tissue gutta-percha,' is very J)refera,ble to the dry dress ; or, if there be much secreti&n from the glands on the nipple, after cleansing its surface, .some dry powder, such as carbonate of magnesia, oxide of zinc, or starch powder is beneficial. When actual congestion of the gland-tissue exists, mechanical means should be used to reduce it. Supporting the gland with strips of plaster and a bandage is sometimes very useful.- When inflammation is excited, local applications of warmth and moisture are indicated, and the con- stitutional condition of the sufferei; demands special attention. When suppuration has taken- place, its relation to the adjacent parts and the exact site of the abscess when formed should be carefully examined. Great diversity in the pro- gress, duration, and sufiFerings of the patient depends upon the locality of the pus. It maybe situated over the hody of the gland, within it, and beneath it. When overlying or siipei^eiai to the body of the breast, the course of the disease is rapid, the pus soon j!oints'and'escapes,and the wound heals. In those cases the constitutional disturbance is usually trifling. Water-dressing before and after the escape of the pus is pre- ferable to the heavy poultjees iisually employed^ The entire organ may be supported- with strips of adhesive plaster and a bandag;e during cica-' trisation. But a bandage dexterously applied should be always used. Both the local and constitutional symptoms are m-ush more severe when inflammation affects the body of the gland, and pus collects between its lobes. The progress of the disease is tedious, pointing of the pus slow, and the exact spot at which it may reach the surface is for a long time doubtful. In the majority of cases it makes its way between the ducts and reaches the surface near the areola or within its area ; usually to the sternal side of the nipple, where' the gland tissue is thinnest. The surgeon should note this fact, for as soon as he can detect a softening of the cutis, by ulceration, he may, with advantage, make an incision at that spot, and thus give immediate relief by facilitating the escape of the pus. In these cases recurrent abscesses are not uncommon, and therefore the incision should be free, and its premature closure by adhesion must be avoided. All incisions should be made in a line parallel to the course of the ducts, never transversely to their axis. Manual pressure to Ilaateu the escape of the pus is not admissible, the natural contractility of the tissues being quite sufficient for the pulposS. When the abscess forms behind the breast the local appearances are quite characteristic. The gland itself seems little involved, but it is pushed prominently forwards and seems to repose upon a cushion of fluid. To the touch the elasticity of the swelling is very striking, and, without pro- ducing additional pain, a slight bulging of the walls of the abteess niay' sometimes be produced at the periphery of the gland when, with the palm of the hand and outsprejd fingers, com- pression is made from the frOnt backwards against the thorax. The patient should be re- cumbent. The pus in theSe cases often - points somewhere around the borders of the ' body of the gland. During the time occupied in the formation of a mammary abscess and its local treatment, the- constitutional powers of the patient must be well supported, and the general health maintained by every means. The segiteltB of Buppnration in an organ com- posed of So much connective-tissue, and endowed' with its peculiar-function; frequently cause great trouble. They aire protracted induration, si^usesj' and fistulse, through which last the milk per- sistently escapes. Induration- of the whole or part of the breast subsides when lactation ceases, and the organ in due time resumes its healthy state. Sinuses ' and fistulae may require incisions; but the ordinary plan'for their cure should he adopted before having recourse to a treatment often involving much subsequent deformity. At the 'time for weaning the infant inflamma- tion rarely occurs. Considerable milk-congestioa of the secreting structure may sometimes produce irritation and inconvenience, to be re- lieved by mechanically dra-wing the milk in just sufficient quantity only to diminifeh-the fulness.'' Galacticele. — An accumulation of milk, to which the above term is given, forms a tumour in the connective-tissue of the organ, and results from the biirsting of a lactiferous tube. The swelling' al-ways appears first during lactation. It may vary in size from time to -time ; sometimes enlarging rapidly as suckling goes on. Two ■varieties are met -with. In one form there is a single swelling near the nipple, quite superficial,' and quickly recognizable by- its objective signs. In- the other there may be several swellings dis- tinguishable in the substance of the gland, as *ell as on its surface, all of comparatively small size, very firm and globular. In the same gland they vary very much in size, and in -the degree of resist ance they offer to manipulation. The' discrimi- nation between these tumours and others -in the breast is easy, if the surgeon is able to ascertain -with exactness that the swelling appeared some- what suddenly during' suckling, and that its size varied conformably with that function. '■ ' In cases of long standing, the contents of the cyst become solid in proportion to the quantity of the fluid constituents of the milk absorbed, and the cyst wall itself is very often rigid and even m^ become gritty. Treatment. --The treatment of this malady consists in cutting into the cyst, removing ito contents, and allo'wing the wound to heal by granulation. BREAST, DISEASES OF. 160 B. The diseases affecting the mature gland, in its passive state, from the age of puberty to that period of life when the occtametiiii eease, may be grouped as fdlows : — t)ief fictional affections, or those which are characterised by changes in the secreting portion of the gland, accompanied by more' or less induration, inconvenience, and pain; the organie, or those diseases characterised by some new-growth, formation, or tissue-struc- ture altogether a supeiaddition to the orgaUj and growingwithin its sphere of nutrition, often resemblingi mora or less, gland-structure in composition ; and- others the minute elements of which are Bucleated cells of various- sha'pes, de- finitely and diversely arranged. ■In this state of the breast inflammation rarely occurs. Hevertheless, both theaoute and chronic varieties of that- morbid process ter- minating in abscess are met with, and careful discrimination is necessary to avoid mistaking such diseases for tissue-tumours, especially in patients above forty years old. The history of the case, tactile examination, and the variations occurring during the progress of the affection^ commonly suffice for the detection of such cases; The tr^tment shoulid be the same as for abscess in'geneibli IFunotional Derangements. — The fonctional derangements of the breast in its passive state demand special attention; They are charac- terised by a peculiar activity of its secreting portion, which undergoes structural changes of a specific kind. When the tissues composing a mature gland, but perfectly passive, are ex- amined with a microscope, the cseoal termina- tions of the ducts are scarcely perceptible, and Little else thau'fibre^tissue is seen. Here and there, ■ perhaps, eseoi may be detected con- taining minute aggregations of epithelium. But when, under some sympathetic excitement, with derangement of the functions of the pelvic generative organs, the secreting cells of the gland become active and are distended with epithelium, they induce more or less enlargement of the breast. But of suoli affections there is this important fact to be noticed. The whole breast need not be necessarily involved. On the contrary, one lobe only may bo &oited, and when this occurs the existence of a tumour is declared.- When, after excision, such enlarged lobes are carefully examined with the micro- scope, normal gland-tissue is seen, the csecal ends of the ducts are readily recognised, and their immediate association with the exeretory ducts may be observed. The former are gorged , with epithelium ; and true gland-tissue, less its peculiar secretion, has been developed. Symptoms. — ^Associated with this state of the tissues ofthebreastithepatientcoinplains-of pain, both locally and spread over a very wide area. To express as brtefiy as possible the superficial regions affected and over which pain is felt, the reader must be reminded of the distribution of the nerve-filaments of the lower cervical plexus, and of the dorsal from which the second, third, fourth, and fifth middle and anterior intercostal aen-es pass off. From these, special filaments are distributed to the breast ; and to the site of exit of one or more of them at the intetoostal foramina; the couirse of the pain is referred by the patient. The Skin of the neck, shoulder, side of thorax, and' inside of arm receives filaments from' the same Source. Hence an explanation of the widely-fliffused pain. It is of the first importance to disqriminate between this state of the gland-tissue and sub- stantial new growths, especially because the latter cannot be removed by natural processes, whilst the former most probably will be. The objective signs, are the following :— to the touch the excited gland-tissue is nodular, irregular over its surface, mnch identified and mingled with the body of -the organ.' If the whole breast be laige and relaxed, the tips of the flngfersmay be insdnuated'between the borders of the indu- rated lobe and the lobes not affected. If the entire body of the gland be mqrbidly firm; it feels like a disc-shaped mass lying on thp thorax, under the borders of which the fingers can be pressed. Occasionally, at one or more spots along the periphery of the gland irregular nodules are perceptible, projecting into the con- nective-tissue around them. When one lobe is affected, the shape of the induration' correspond- ingwith that of a lobe, namely, broad at the periphery and gradually narrowing towards the areola, may be detected. Pain as a subjective indication is of great assistance in the diagno- stlcation of these cases ; but the source and course of the pain must be carefully traced. Generally manipulation of the indiiration pro- duces increased pain ; occasionally touching the induration, even however gently,- is intolerable, and persistence in or 'repetition of the act strongly opposed by the sufferer. Light pres- sure should be made pvei^ the interoosial fora- mina,' both the 'Iniddle' a*id anterior, when the pain excited thereby will correspond with the nerve-fllametits of the affected lobe. Usually, pressure along the upper dorsal, spinoas processes excites pain also. The morbid affections above described occur in single' women, married but sterile females, and young -widows; at ages be- tween twenty years' and forty. More or -less disturbance of the catamenia co-exists, either in relation to the frequency or quantity of- the discharge. The patient complains of languor, inability for bodily or mental exertion, and is desponding and often alarmed for the possible consequences of the affection suggested by sym- pathising friends. She becomes irritable; restless at night, loses appetite for food, as well as all desire for social enjoyments, and becomes highly susceptible and emotional. DuaNosis. — ^An exact diagnosis.of these histi>- logical changes maybe made if the manipulator examines the organ methodically. He should, first, gently grasp the indnrition between the •thumb and fingers, when it will be distihctly ap- preciable. Afterwards, placing the palmar sur- face of the fingers over the surface of the breast and gently pressing b-ackwards against the thorax, the induration cannot be detected. Should there still remain any doubt on the subject, let the patient recline o» her opposite side on a sofa, and in this posture; if thete -exists a substantial new-growth, the integiiment is ' usually elevated by It. ,■'■,'' ■' Tbbatmbnt.— The treatment of these cases consists in attention to the geiieral health. Every 170 hygienic direction should be enjoined, and such medicines administered as conduce tx) its im- provement. Local soothing applications are UBually futile, and, except in those cases of ex- treme pain, are not advisable, since it is desirable to avoid manipulation of the part, and the frequent recurrence of the patient's thoughts to it. Should the gland be heavy and pendulous, a suspensory bandage, as thin as possible, may be adjusted. New Formations. — -We shall next describe the diseases of the mature gland arising from the development of new formations— either of tissues constituting new-growths; or of conditions causing collections of fluid of distinct and specific kinds. All of these may be thus arranged in three groups : — first, the fluid tumours ; second, the solid: and, third, those composed of both solid and fluid. A. Oysts.-^-The fluid ttimours, commonly termed cystic, consist of a membranous sac with its contents. Now, calling to mind the histolo- gical divisions of the breast, and dwelling on the structural differences between its parts, the secreting apparatus and the excretory, there is little difficulty in assigning to the cysts their true histological affinities. Thus there are cysts associated with the secreting apparatus ;, others with the excretory, the ducts ; and some due to the extravasation of the gland's, secretion, the milk, into the connective tissue, Efiusionsof blood also give rise to the development of cysts, either in- dependently of other diseases or associated with them. Another variety of cyst is produced by the development of entozoa, notably of echino- coccus hominis. An ordinary examination of the fluid derived from these cysts at once es- tablishes the fact that heat and the admixture of nitric acid produce coagulation in that abstracted from some of them, whilst that from other cysts remains unaffected by the treatment. The cysts are thus divisible by the nature of their contents into two distinctly defined groups : — a. Those containing fluid without the admix- ture of any coagulable element. h. Those enclosing fluid which does contain coagulable material. Otbcr characteristics of these two fluids are not less conspicuous. J?roni an objective point of view all cystic tumours of this gland may be classed in two groups, thus : — first, those associated with its duets, the evidence of which is afforded by the escape of fluid at the nipple ; and secondly, those not connected with the ducts by any such evi- dence. The following tabular arrangement will place before the reader, at a glance, all the varieties of cysts met witli in the breast. I. C7/sts associated with the ducts, communi- cating and connected with them. 1. Containing milk. 2. Enclosing growths ; with serum, co- agulable and often tinged with blood : — a. Adenoid growths. b. Granulation cell-growths, ». Cancer. Cysts not connected with the dticts. 1. Surrounding efiused blood, 2. Enclosing milk. BKEAST, DISEASES OF. 3. Simple cysts. 1 Fluid not coagu 4. Entozoon cysts. J lable. 5. Investing growths; with serum co- agulable, tinged with blood and containing cholesterine :-r- , a. Adenoid growths. . . b. Granulation cell-growths,, c. Cancer. 1. We have described above, under the name gcdacticele, a tumour observed di»"ng. suckling and composed of milk., But, occasionally, the sur- geon is consulted about a swelling which, at first sight, would seem to have no reference to that function. Nevertheless the milk, or aU that remains of that secretion, constitutes its entire bulk. If exact enquiry be made, the patient states that a tumour has existed, unaccompanied ■by pain, from the perio.d of the last , weaning, perhaps not having been observed until the gland ceased to secrete,. and that its size slowly d- minished until a certain period, since which it has remained of unvarying bulk. This decreasn is due to the absorption of the serum of the milk, and the solid parts renjain. The cyst should bo incised, the contents removed, and the wound allowed to heal by granulation. Cysts containing the solid parts of the mill! are sometimes associated with perfectly new growths of the glandular type. 2. True sero-oysts, that is to say, a collection of serum circumscribed by a fibrous membrane, are frequently met with, and are most commonly associated with adenoid, granulation, and can- cerous growths. They occur in the breasts of middle-aged women. The fluid which these cysts contain is sometimes quite dear, and of a yellow tint ; at others it is tinged with blood- colouring matter, and is turbid. It always con- tains some constituent coagulable by heat and the admixture of nitric acid. These are the exudation-eysts of the mammary gland. After the fluid has been removed with a trocar and canula the cyst soon refills, 3. Other cysts containing a fluid like serum, until its composition is carefully examined, aro developed in the breast, and are probably asso- ciated immediately with the secreting part of the gland. For' the sake of identification the writer would designate them mueons cysts. The con- tained fluid is not coagulable by either heat or acid. Its colour is brown, more or less in- clining to a greenish hue ; it is opalescent, of variable specific gravity — about 1020f rather greasy when rubbed between the fingers, and exhibits an alkaline reaction. When sufficient quantity is collected in a test-tube and allowed to cool, in a few hours the lowermost stratum of the fluid becomes clearer than the upper. . The uppermost always remains opalescent. If a little of this last be examined with a microscope, oil globules are seen, together with the bodies called colostrum cells. The greasy nature of the fluid can be detected by smearing a drop of it on a piece of glass. The development of these cysts is not very common. We may here remark that they seem to have escaped the observation .of suigeons, as no special notice of them occurs in the most recent monographs. Yet they are so distinctly separated from all the other cysts which mo BKEAST, DISEA.SES OF. 171 formed in the breast, iu respect of the composi- tion of their fluid contents, their progress, and their prognosis, that they constitute a marked, distinct, and isolated . class We meet with ^hem in the breasts of single women, in married but sterile females, and in widows between forty and fifty years of age. Usually they are acci- dentally discovered in any quarter of the gland when about an inch in diameter. Their shape is globular or Ovoid ; to the touch elasticity \s the main feature, and if sufficiently large and superficial, .fluctuation may be detected. In spme instances the tips of the fingers may be insinuated into a sort of furrow around them. Pain is rarely complained of. The treatment consists in emptying the cyst 'with a trocar and canula. After this the fluid does not again form. These cysts usually appear singly and in one breast only, but the writer has seen a patient in whom they were multiple and on both i. Cysts containing blood — hamaiomtfta, are very rarely formed in the breast, except in association with some new-growth ftom which blood, or more often bloody serum, oozes. 5. True entosoa-a/sts are developed in the breast. They are certainly rare, stnd cannot be distinguished from other cysts until incised. Extirpation by excision is the speediest means of effecting a cure. B. Solid Tumours. — ^We have next to de- scribe the solid tumours. These are essentially new growths of tissue superadded to the normal gland. Generally, therefore, a characteristic feature of the existence of such growths is an in- creased bulk of the affected organ ; another, the firmness or resistance to pressure with the fingers when contrasted with the group of tumours be- fore described. The solid tumours have long been classed in regard to their local and constitutional effects, and their results on the life of the indi- vidual affected with them, into two groups — the innocent or harmless ; and the Tnalignant or life- destroying. 1. Admorna. — In the first class are placed those growths more or less closely resembling in their tissues those composing the glandular structure of the breast. Various terms have been assigned to these tumours, namely. Chronic mammary tu- mours, Pancreatio Sarcoma, Tumeur ad^noide, Corps fibreux. Hypertrophic partielle, Mammaiy glandular tumour, Kbroma, Adenocele. Their composition is chiefly fibre-tissue, the cseci or acini of secreting structures, with more or less distinctly marked traces of ducts, being inter- spersed throughout the mass. The elementary nucleated cells are those of the gland and fibre- tissues. Adenomata are developed in the breasts of young, unmarried womeii from the age of puberty uptrards ; rarely after thirty, but very commonly before that age. They may be intraglandular, occupying the substance or body of the gland, and having the normal gland-tissue investing them. In other instances they seem to be at- tached by a kind of pedicle either to its surface or margin. In every instance they are placed within the fascial investment of the organ. When attached, as just described, their remark- ible mobility, slight lobulation of surface, and firmness, coupled with the youth of the patient, are sufficient indications of the harmlessness of their nature. Usually they occur singly and in one breast; they may be multiple and in both breasts. The only means by which they can be removed is excision. However large the tumour, its removal should be always attempted without cutting away any portion of the normal breast. In most cases this can be done, especially if the patient be youthful and the growth of medium size, even should it be developed in the body of the gland and extend through it to tho pectoral muscle. After thirty-five years of age it is expedient to remove the breast as well. Want of space precludes a lengthened histo- logical description of these growths. It. must suffice to state that a section shows a solid, uni- form surface, divided into lobes and lobules by fibrous septa, sometimes slightly broken up by fissures or clefts in which there appears a little clear tenacious fiuid. The growth is often very succulent, at other times only moist ; its hue may be greyish, yellow or almost white. Its vas- cularity is scarcely perceptible. The prognosis of these cases is invariably favourable. In many instances excision is not necessary, and the surgeon must be guided in recommending an operation by the exigencies of the case specially under observation, . 2. Fatty tumour. — Llpomata or masses of adipose tissue are developed in the breast, or rather in relation with it,, to speak with accuracy. They are characterised by the usual indications, and require no special mention. » 3. Nsvm. — It may be questioned whether nsevus, or a growth of true trabecular vascular fibre-tissue, is ever developed in the substance of the breast, that is to say, in the gland-tissue. The integument around the mammilla may cer- tainly be so affected in early life before the de- velopment of the gland, and a subcutaneous nsevus may exist at the site of the future organ ; but to describe such a growth, in a girl of six years old, as a recent writer has done, as an example in which the whole organ was like a sponge and as large as half an orange, must be regarded as an error in pathology. 4. Fibro-plastie. — Under the term 'fibro- plastic' we include a group of new-growths composed of elementary nucleated cells of a. fusi- form or oval shape, disposed in a stroma of more or less fibre-tissue. They are developed in women of middle age, increase rapidly, and after excision are liable to grow again. 3. Colloid. — Colloid growths are very rarely met vrith in the breast. They appear in middle life, and are not distinguishable from other solid tumours until after excision. 6. Carcinoma. — Carcinoma, , commonly' called cancer, is developed in the breast in two distinct forms. The first, and most common, is that variety which is due to infiltration of the normal tissues of the gland by the elementary cells of cancer. It constitutes the scirrhous variety, the carcinoma Jtbrosfim of the present day. The second is that kind which is produced by the development of a mass of true cancer-growth, and is_ termed tuberous, often mediillary. Both varieties are met with in women after forty years of age, but the first much the most fee- 172 BRKAST, DISEASES OF. qaently. Prericusly to that age the disease is rare ; from forty to fifty it is most commonly seen ; and it becomes relatively less frequent as age advances. A larger number of married women are afiFected by it than single, and prcdifie ■women who have fenckled their children are quite as prone to the disease as the sterile or those who have not suckled. Stmetoms. — Scirrhous cancer commences in any region of the mammary gland, although most frequently perhaps in the axillary segment. A small,' &rm nodule is usually accidentally dis- covered, -without the attention of the patient having been attracted to it by pain. Earbly, the -whole organ is simultaneously infiltrated, but most frequently one lobe only is affected. The infiltration is often central in the body of the gland, especially -when the organ is atrophied, and the reverse' occurs -frhen the ex- treme edge of a lobe is affected at it? periphery. The infiltration may steadily increase until the -whole breast forms a rigid; sblid mass; but most frequently the larger part of the organ remains unaffected. The disease ^-ves rise by its con- traction to much deformi-ty of the region, to dimpling, corrugation, , and irregularities of the otherwise rotund integumental surface. The nipple, just in proportioil' to the effect ' of the gro-wth upon the ducts,, becomes retracted or dra-wn to-wards the tumour. Such are the ordi- nary objective signs of inflltKiting cancer in its early, stage. The progress made by the disease is subject to very remarkable variations in differ- ent individuals, and the stage above described may be long delayed. In some cases many months or even years may elapse- before the gro-wth assumes any grave importance. Sooner or later, ho-wever, the integumerit over the gro-wth becomes adherent to it,' infiltrated, and red, and advances towards ulceratibn. ' An' ulcer no-w forms, the edges of -which are everted, ragged, and Etttached to the growth beneath.' A hole extending into the tumour becomes deeper and deeper ; ichorous discharges, more or less profuse, continue -without much pain; and the patient becomes at last -worn-out, or succumbs to the ravages of a cancerous grp-wth in a vital organ. The tiiherous variety commences in a siuall circumscribed, globular nodule in the body of the gland ; gro-ws rapidly ; separates the lobes of the organ ; extends equally in all directions ; and becomes adherent to the skin, -which commonly sloughs and allo-ws of a protruding, fungating mass. In both varieties the axillary lympiaticl glands sooner or later become involved in the disease, -which may also spread to those in the neck and -within the thorax. , TEBATMENTi— Local applications ejtert, little if any influence on the gro-wth of cancer, but certainly those which reduce the local tempera-, ture are the best. The vital .po-wers of the patient! should be supported as much as possible by hy- gienic measures, and especially by ferruginous tonics. The removal of , the primary growth before the contatni nation of the lymphatic system is_ of great importance, but -whether, by excision with a scalpel, or W means of escharotics, space will not admit of discussing. The writer iuclities: to the first method in the majority of cases. C. Mixed Tumours.^-To the group of mixed ttimours belong: — 1- Those composed of- cysts, intracystic gro-wths; and solid interspersed massesof new tissue.' 2. GramdaiioncysiB — cysts with growths attached to their walls, the elemen- tary tissues of which resemble those of ordinary granulation-growths — whence the term applied to them. 3. Cysts, so-called, often formed upon the surface of cancers, in consequence of the slow exMatibn of serum from the growth' itself. 1. Tumours of the first class belong pis,tholo- gically to the group of adenoid formations, and although they differ so remarkably in their ex- ternal objective appearances, they are, when un- alloyed with other gro-wths, perfectly harmless. The sero-cystic disease of Brodie, and' the pro- liferous cysts of Paget belong, to thi^ class. . 2. The granulatidn-cj/stic gro-wths" cdhslatutB a class of tnemselves. It isonly of late years.that attention has been attracted to them. They are rarely met with, and when pure are unattended by untoward circumstances. 3. To the third class belongs a group of oases thoroughlycancerous in their nature, and differing only from the ordinary forms of that disease by the accidental formation of cysts. /SeeTuMOUBs. III.. Diseases of the Malef Breast.-^Tbe male has . sometimes a -Vrell-developed mammary gland, and the part is subject to the same dis- eases as the female. But the simple enlarge- ment of the organ is harinlessi and should not be interfered with. At the age of puberty the mammary region often becomes painful, o-wing in part to the pressure of the d^ess upon the mam- milla and the rudimentary organ. Infiammation followed by suppuration has been observed at this time. ly. niseaaea of the Ifipple.— A defectm formation of the nipple is of grave importance, and when it exists measures should be adopted to assist its elongation. This is , to be done by usin^ an exhausting glass, such as those em- ployed to empty the gland bf milk. Inflammation and its effects produce, mudi suffering, and at tlie period of suckling frequently excite deep-seated mischief. The small ulcers, called ' cracks," ' chaps,' &c., which form between the rugae pn the apex and sides of the nipple, may be cured -witi an application of water-dressing, or by powdering the part -with carbonate, of mag- nesia or oxide of , zinc, far more readily than with ointments. ' P(nci%Uov^ cittaneotts growths occur on the nipple, and should be excised. Cystic follicular tumours are sometimes seen within the zone of thie areola. See Niitle, Dis- eases of. JOHK BiRKBTT. _ BBiiATH, The.— The expired air, or what is familiwly ternied the breath, is important both from an aetiological and, a clinic^.! point of view, and the object.of thg present article is to present a. brief summary of the main facts relating to this subject, -with which, for pr,actical purposes, it is necessary to be acquainted. , ; 1. The eetiological relations of the breath will 'bp nibr.e appropriately discup^sed underi the gene- ral subject of ffitiology {see Di^ease-J, Causes .of), -but a few of the more striking 'examjple3>of the manner in which it affects the hesJti may bo given heie. It is well Juiovn tbat the expired air, it re-breathed ty the same individual -with- out having been purifled by a proper admixture wi^h atmospheric ail, virill prodiice senous effects upon the economy, and vnll ultimately lead to death by asphyxia. Again, the breath of a number of persons collected together in an ill-ventilated plaee may prove injurious to sucli individuals ; the iiupure atmosphere thus generated tends to lower the general hfealth, to retard the develop- ment of the young, to increase the virulence of infectious diseases, and to ^redisjose to jul- monary affections. Indeed, sDmewriters regard le-breathed air as one of th6 most promitetit causes of pulmonary phthisis. TurthBr, un- doubtedly the expired air is a most important (diannel by which thepoison of different infective diseases— for example, that of measles, scarlatina, or diphtheria — is conveyed from one individual to another. It has been affirmed that phthisis can be transmitted diieetlyiin this manner, but adequate proof of this statement is entirely i wanting. 2. In a clinical point of view, the e^ired air may afford useful information in diagnosis ; or it may present characters giving important indi- cations for prognosis and treatment. It niight be requisite in different-^ cases to submit the breath to a more or- less complete examination, and, the following outline triU serve to suggest the particulars to which attention should be directed in this examination, and to point: out the practical uses which it may serve. a. The breath has been made use of to distin- guish between real ani appmrent death. For this purpose a delicate feather or a light is held before tiie mouth or nostrils, and it is noted Whether either of these is disturbed; or, a cold mirror isylaoed before thft mouth, when; if breathing is going on, its surface willbesclouded by the nioisture condensediupon it. These t^sts are, however, not eonsidered very relial)le; b. The temperature of the Expired air may be important to notice. In some conditions it becomes exceedingly coldi and t^is may be -readily perceptiblen to the hand, the breath thaving a chill feel, or it may be visible in cpn- sequence of the moisture in the expired air being condensed, even when the surrounding atmo- sphere' is warm. This phenomenon is observed, for instance, > in the; oollapse-etage of chp^era,. On the otiier hand, tbe temperature of the breath may be raised more or less, as in febrile diseases. e, Ohepiical examination of the breath may prove ;.;of service, and it is. probable that this mighti^aflbrd useful infonnatioUf if It were re- sortednto mbre frequently than is\ the custpm at present- lu ^^6 &^st |ilace this examination may be en^loyed to determine the proportion of car- bonic acid present. In certain affections, as during at attack of asthma, or in cases of exten- sive' bronchitis, the amount of c^bonic acid in the -expired air is more or less increased ; in others, such as tin thecoUapse-stage of cholera,, this ingredient may be very deficient. Again, chemi- cal examination of the breath may reveal the presence. of a poison in the system, introduced from without, for example,. hydrp<^nic acid. It has- also been employed to show the existence of deleterious products generated within the body. BEEATH, THE. 178 especially in cases of renal disease. It is affirmed that ammonia may be detected, i° the breath in some cases of this kind, by holding a glass rod dipped in hydrochloric acid before the mouth, the ammonia ^eing a product of the de- composition o{ urea. d. Microscopio examination of the expired air has be?n attempted, but at, present no results of practical value: have been obtained. e. The odonr of the. breath is the most impor- tant character demanding attention in a prac- tieal point of view.. It is easily recognised, and the practitioner slipuld always be on the aleit to notice the smeU of the breath of a patient, as this often affords inaterial aid in diagnosis, and may even reveal certain morbid conditions which otherwise are liable to be entirely overlooked. Besides, patients not uncommonly seek advice on accQUjit of ' foulness of breath,' as a symptom forwhieh .they require special treatment. The following summary will indicate the principal circumstances under which this clinical phen,ome- non may j>rove of service in diagnosis, and in the courseiOftheTepiarks it will be pointed out in what conditions the breath is particularly offensive. At the outset it must be observed that in some individuals the breath seems to have naturally a more or less disagreeable odour, •which; cannpt be ; referred to any particular cause, and this amounts occasionally to extreme foulness. In feinaJes. this may only be noticed at certain periods,, and in some instances it seems to pass off in course of time. Again, it must be borne in mind that the Ijreath is fre- quently unpleasant, either temporarily or con- stantly, from persons eating certain articiles of food, or indulging in certain habits, such as excessive smoking, chewing tobacco, &c. (i.) The odour of the expired air may aid in re- cognising poisons in the system. The smell of pruasic acid or laudanum, for instance, may be revealed when, either of these, is present in the Btomach< Alcohpl, however, chiefly demands at- tention in this relationship. In cases of acute al- coholic poisoning, the odour of the alcohol or of its products is. at once apparent ; and in persons who are found in a state of unconsciousness, the cause of which is not known, the smell of the ^breath is made use of as one of the diagnostic signs of drunkenness, though it must be taken ■with great caution. It i? in the chronic forms of .alcoholism that the breath gives the most valu- able information. In very marked cases of chronic alcoholism it has an intensely foul odour, which is quite characteristic; but it gives extremelj impoj;tant_.indications in less confirmed cases, where the other symptoms of alcoholism are not so apparent ;. and especially does it enable us to de- tect dram-drinkers, and to explain the symptoms of vhich they so frequently complain. These per- sons, if their habits are inquired into, generally give themselves an excellent, character for tem- perance, and seem entirely to, forget that those with whom they come into contact are endowed with organs of smell. Again, the breath may reveal the presence of certain metallic poisons in the system, of which mercury is the most impor- tant example, but lead may also affect its odour. The expired air is, said to present the odour of ammonia ia exceptional instances of urtenda. 174 BREATH, THE. due to the exhalation of carbonate of ammonia derived from the decomposition of urea. (ii.) The breath has a peculiar, or more or less disagreeable odour, in connexion 'vrith several diseases. That ■vrhieh is associated with the febrile condition is -well known. In various dis- orders of the digestive organs the breath is often very offensive, but it is not practicable to refer any particular odour to particular diseases of either of these organs ; it may, however, beafirmed that an unpleasant smell is frequently associated with habitual constipation. In eases of stercora- ceous vomiting the breath mayhavea faecal odour. In this relation it may be mentioned that in some cases of phthisis the writer has notified a sickly smell of the breath which is quite charac- teristic, and which seems to depend upon the state of the stomach. In cases of cerebral diseases also, the breath often becomes exceed- ingly offensive, on account of the condition oi the alimentary canal. Local morbid conditions about the mouth, throat, or nasal cavities con- stitute a most important class of affections which influence the odour of the breath ; in many cases it becomes extremely foul, and may be quite peculiar in its characters. Among these condi- tions should be specially mentioned want of clean- liness of the month and teeth; decayed teeth ; dis- eased bone in the mouth or nose ; ulceration or gangrene about the mouth, especially eancrum oris, and gangrenous ulceration along the gums ; suppuration, ulceration, or gangrene in the throat, either ,of local origin; or associated with syphilis, scarlatina, diphtheria, &c. ; ulceration of the nasal mucous membrane, and chronic ozseoa; aiid malignant disease. The smell of the breath is of special value in drawing atten- tion to some of these conditions, for they may exist without giving rise to any local symptoms whatever, and the patient may be quite uncon- scious that there is anything wrong. Several striking illustrations of this statement have come under the writer's observation. Again, certain conditions of the respiratory organs are liable to affect the odour of the expired air, and may render it unbearably foetid. Among these may be mentioned sloughing ulceration about the larynx, pulmonaiy gangrene in any form, and the decomposition of retained morbid products in dilated bronchial tubes or in certain cavities. Here, again, the smell of the expired air may reveal what otherwise is liable to be entirely overlooked, and especially when the patient coughs, so as to expel some Of the retained air out of the lungs. Lastly, the breath may hare a peculiar odour in some special diseases, such as pyaemia and diabetes. Tbeatment. — It is only intended here to offer a few remarks as to the treatment oi foulness of breath. The first great indication is, of course, to seek out the cause of this symptom, and endeavour to remove or remedy this, by which in a large proportion of cases a cure may be readily effected. The habits should be duly regulated; the mouth and teeth properly cleansed ; the ali- mentary canal maintained in good order; and any special affection requiring treatment attended to. When unpleasant breath depends on the Bl^omach, it may often be improved by taking eharcoal powder or biscuits, at the same time BEIGHrS DISEASE. remedies being 'employe4 suitable for the parti- cular affection present, and calculated to promote the functions of the alimentary canal, the bowels being also kept freely open. When the bad smell depends on local causes, it may be dimi- nished by the use of antiseptic mouth-washci and gargles; such as soliitioB of Condy's fluid, carbolic acid or crea'sote. Antiseptic inhalatiom are indicated when the respiratory organs are accountable for foetor of breath. Feedehick T. Eobebm. BBEATHIIfa, Disorders of. See Eespiba- TiON, Disorders of. BRIGHT'S DISEASE.— The term j Disease is now universally recognised as generic, and as including at least three different dis- eases of the kidney. Each of these maladies in- volves chiefly one of the individual structural ele- ments of the organ, and only secondarily affects theothers. Thereisthus a disease originatingre- spectively in the uriniferous tubules, in the blood- vessels and particularly in the Malpighian tufts, and in the fibrous stroma. That which originates in the tubules is always inflammatory in its cha- racter, althotigh the inflammation may be acute or chronic ; that which commences in the vessels consists in a peculiar degenerative change, the so-called waxy, lardaceous, albuminoid, or amy- loid degeneration ; that which is proper to the stroma is an extremely chronic process, supposed by many to be inflammatory, but as it appears to others, rather of an hypertrophic character. In the following article are described : I. The inflammaiory affection, affecting the tubules, or the stroma, or both. II. The waxy or aitiyloid affection, originadng in the vessels. III. The cirrhotic or gouty affection, originat- ing in the fibrous stroma. DEFiOTTioNa. — L Inflam'matory Brights dis- ease is an acute or chronic affection of the kidneys; caused by exposure to cold, and by scarlatinal and other blood-poi^ous ■; consisting in inflainmation of the elements, passing through various stages of transformation, viz. inflam- matory enlargement, fatty degeneration, and atrophy; characterised in the earlier stages by di- minution of urine, albuminuria, frequently h«emi^ turia, tube-casts, and dropsy ; in the later stages by the same syniptonis, in a more or less marked degree, with Secondary changes in the heart, blood-vessels, and other organs ; terminating fre- quently in recovery in the early stage, rarely in the later, often in death by dropsy, ursemia, or intercurrent affections. II. Waxy Brighfa disease is a chronic aflec- tion of the kidney, caused by phthisis, syphilis, caries, suppuration, fend other exhausting condi- tions ; consisting in waixy or amyloid degenera- tion of the Malpighian bodies, small arteries, and sometimes the basement membrane, with, in many cases, transudation into the tubules ; pass- ing through various stages Of transformation, viz. simple degeneration, enlargement from trans- udation, and atrophy ; characterised by a large flow of albuminous urine of low specific gravity, and absence of dropsy ; often attended by evidencus of waxy disease of othet 'organs, particularly the liver, spleen, and intestinal canal; resulting pro- BRIGHT'S DISEASE. 175 bablyin some cases in recovery, usually in death by exhaustion, uraemia, or coexisting affections of the kidneys and other organs. in. Cirrhotic Erighfs disease is a chronic afifeetion of the kidney, caused generally by the abuse of alcohol, sometimes by the poison of gout, occasionally by plumbism, and by unknown conditions ; consisting in increase of the fibrous stroma, Tfith thickening of the capsule, and iilti- mate atrophy of the organ ; characterised by a very insidious commencement, by the absence of the early symptom? of ;either of the other forms, by albuminuria, at first slight, but possibly absent, and by the ultimate appearance of en- largement ' of the heart, polyuria, albuminuric retinitis, cedema of the lungs, and uraemia; re- sulting ultimately in death from ursemia, oedema of the lungs, or other intercurrent affections. Etiology. — I. Of the inflammatory form. Cold is the commonest cause in the adult. It acts especially on those who have been exposed to its influence whilst perspiring. It frequently contributes towards the production of the disease in persons dtherwise predisposed. Various blood-diseases, while they induce temporary albuminuria along with their more ordinary symptoms, have renal inflammation as a common sequela. Among these scarlatina occupies the first place, diphtheria stands next in order, fol- lowed by erysipelas, measles, pyaemia, typhus, ague, acute rheum&tism, and pneumonia. Many of these maladies being most common in child- hood, it follows that in the earlier years of life they are the chief causes of inflammatory Brijght's disease. Pregnancy, heart-disease, ^out, and malaria contribute towards its production in some cases ; and the undue use of cantharides, turpentine, or alcohol may also be reckoned as causes. II. Of the waxy form. Constitutional syphi- lis, phthisis, prolonged suppuration, caries or necrosis of bone, and other exhausting diseases, such as cancer and chronic rheumatism, induce this degeneration. There is at present no satis- factory evidence as to the precise connexion between these influences and the morbid pro- cess. III. Of the cirrhotic form. The commonest cause is the abuse of alcohol,- particularly in the form of ardent spirits. After this, though at a long interval, rank gout and lead-poisoning. Congestion from cardiac disease is also by many authorities, but erroneously, held to be a cause. [See KiDNErs, Cbngestioil of.) As experience shows that the disease is often met with in people who have neither indulged in alcohol, been exposed to lead, nor suffered from goutj it is obvious that other eficient though yet im- discovered causes must exist. Anatomicai. Chaeactebs. —I. Of the inflam- matoh/ formi When a case of this kind is pro- longed, the reiial disease passes through several conditions, which, for convenience of description, may be divided into three stages, (a) Stage of ahtioS inflammation. In this stage the kidney is enhirged ; its capsule strips off readily ; its sur- fSice appears more or less red, sometimes of a deep purple colour ; and occasjonally extrava- sations of blood are present in its Substance. On section the cortical substance is found to be relatively increased in bulk. Its vessels, as well as those of the cones, are congested. The struc- ture appears somewhat coarser than natural, while the convoluted tubules often present a swollen opaque appearance, and occasionally contain blood. On microscopic examination the congestion of the vessels becomes very apparent, and the tubules are foiind to be dark and opaque, their lumen being frequently occluded. The individual epithelial cells are granular, and in a state of cloudy swelling. In some cases almost all the tubules appear affected, in others com- paratively few. The enlargement of the organ IS in part due to congestion, in part to exudation into the tubules. As the exudation increases the congestion becomes less marked, so that in the later period of this stage the kidney appears paler and more opaque. Unless recovery or death takes place, this condition passes into (i) The second stage, that of fatty transformation. In this stage the organ is still enlarged. Its capsule strips off readily ; the surface often presents stellate veins, audits colour is mottled. At this time extravasations are very rarely observed, but there are alternating patches of yellowish opaque sebaceous-looking material, mingled vrith more natural structure. On section the cortical substance is seen to be relatively increased. There is no congestion of the vessels, and the Malpighian bodies are not prominent. The convoluted tubules are in many parts occupied by the sebum-like material, and sometimes the. straight tubules present the same appearance. On microscopic examination the tubules alone are found affected. Many of them present under low powers a black appearance, due to fatty degeneration of the con- tents of the tubules. It is in the cells alone that this change occurs, and not, so far as the writer has seen, in the free exudation which binds the cells together. Many of the tubules are completely blocked up by this material ; and sometimes in making the section there is such an amount of oil set free, that it permeates the whole struc- ture of the organ, and is liable to produce the impression that the fatty degeneration is uni- versal. This condition may be developed within a week or two of the commencement of the inflammation, and it may continue for years. During the whole course of the second stage it mu^t be understood that inflammatory action is going on, although much less acutely than at first, and less widely diffused. The disease is sometimes rfecorered from, and if the pStient survive long enough it passes into (c) The third stage, that of atrophy. The organ is then reduced to or even below the natural size. Its capsule strips off with little difficulty, and without tear- ing the surface. The surface is uneven; it rarely appears coarsely granular, as in the cir- rhotic form, but rather presents a series of de pfessions, which give it an uneven or finely granular character. Its colour is very similar to that described as occurring in the second stage, but there is less of the sebaceous-looking inaterial. On section the cortical substance is found relatively diminished. The Malpighian bodies are not prominent. The tissue feels more dense ; and many of the tubules are occupied by sebaceous-looking material. The blood-vessels, ^76 BRIGHT'S and particularly the small arteries, are splerose^; the intima aud the adventitia are frequently, the middle ; coat almost invariably, thickened. The fibrous stroma ig relatively increased, espe- cially towards the surface of the organ, and the tubules may be traced in different stages of" atrophy. On close inspection that atrophy is found to resiilt not from pressure of the fibrous stirbma, but from molecular absorption of the contents of the tubules. Besides the typical form of the inflammatory affection just described, notice should be taken of other varieties, such as the ffhmerulo-nepkritis of Klebs, in which the glomeruli are especially affectisd. The ana- toiuioal -changes met ■ffithfiu other organs are described along with the complications. II. Ot the waxy or am^/loid form. Thischronic morbid process may also, for convenience of description; be dividedinto three stages. Of these the first is, (a) The stage of degeneration proper, in which the organ presents an almost normal appearance. The size is natural ; the capsule strips off readily ; and the colour is not altered. On section all appears normal, excepting that the Malpighian tufts, without being congested, are prominent, and in certain lights may be seen even by the naked eye to present dim translu- eency characteristic of waxy degeneration. On applying a little aqueous solution of iodine, the Malpighian tufts and the small arteries assume a peculiar mahogany hue. On examination with the microscope, the stroma and tubules are found to be healthy, the vascular structures being alone' affected. The affection is often first seen and is most distinct in the middle coat of the arteries, the swollen transverse fibres taking on the colour, and producing what has been described as the ipecacuanha-root appear- ance. How long this condition may last without the tubules becoming affected it is impossible at present to say, for it has only been met with in patients who had died of one or other of the causal complications wMe the renal malady was still in an early stage. Sooner or later it passes, however into the condition most commonly met with, (i) the second stage, that of degeneration with secondary ehariges in tits tubules. In this condition the organ is enlarged. Its capsule strips off readily, the surface is smooth and pale, presenting, in pure examples, little or no mot- tling. On section the cortical substance appears relatively increased, and Ipoks much paler than the cones. The structure ustial.ly is denser than natural. The vessels appear prominent, and the Malpighian tufts resemble minute grains of boiled sago. On the addition of iodine the degenerated parts become characteristically coloured, and stand out prominently from the tubular tissue, which does not exhibit the chaTac- teristic reaction. On microscopic examination the vessels are found altered as in the earlier stage, but the change is more advanced. The stroma is normal, but many of the tubules are altered. Some are blocked up lay a dimly tranfilu- cent, wax-like material, whioK however does not assume the mahogany colour on the addition of iodine. The epithelium in many of the tubules presents a finely granular appearance, and occa- sionally is somewhat fatty, but the epithelium and the hasement membrane very rarely present DISEASE. the characteristic reaction.. This :;hange in the tubules is thus secondary <;o the, degenet^. tion proper, which is confined, to the vessels, and these secondary^ changes' consist jn .somo alteration of the nutrition of the epitHelJum, vri^li exudation or transudation of coagulable material into the lumen of the tubes. This condition may last for years, but should the patient live long enough it passes into (c) the third stage, thftt of atrophy. The organ is then , below, the ndrniii •size ; the capside strips oS readily ;, the su^feco presents an uneven granular appearance, and is pale. On section the cortical substance is fpiind relatively diminished. Itis .small art^ies' are prominent and thickened ; it;s Malpighian bodies are very conspicuous, and are grouped together in consequence of the atrophy of the intervening structure. The stroma is relatively incrg^se^, and many of the tubules are destroyed, wlui(e of tjiose. which reniain not a few present the cha- racters above described as being met with in the second stage. The organ may, in extreme cases, be diminished to less than half its natural size. III. Of the cirrhotic form. The course of this affection is even more chronic than tbi^t oi the waxy form. It , consists essentially in an increased growth of the fibrous .stroma, witli secondary changes, .in the tubules, and vessels. In , an early stage the organ may be found of fully the natural size. The capsule strips off less readily than in health. The surface is somewhat uneven, and may present cysts,. On section the cortical substance is relatively en- larged, and this is due. merely to an increase of the stroma, not to any change in the vessels .or in the tubules. But it is in, the more advanced stages that the disease is commonly seen. Then the organ is reduced in bulk, it may be slightly, it may be to one-fourth of its normal size. Its capsule cannot be peeled off with,out tearing the gland. The surface is uneven and grariutari and often of a reddish colour. On section, the co^'tical substance is found. relatively diminished, its structure being dense and fibrous. The sinall arteries are thickened and very prominent,iall their coats, but especially the middle, being increased in volume. Many of the tabiiles.ate atijophied, but the epithelium of such as, are not involved is for the most part natural. Cyst^ are numerous, and are found in. connexion with the tubules, the Mialpighiau bodip's, and tli,e cells. ' ,,, There are two points worthy of being epgcia^y kept in view by those who desire to attain to i^e^T conceptions of Bright's disease — ^yiz. (iljhat its different forms are very frequently comb?n^Q^ in particular that the,, inflammatory afifectioii la found associated sometimes with, the waxy dis- ease, sometimes witi the cirrhotic ; but that, the desffiriptionp.hera given are deriv,ed from ^ure examples of each process ; and (2) that atropjiy results in all the forms if the disease las^s'lojig enough; that is, that a small, uneyen-surfaced kidney may result from either the inflammatory disease of the tubules, or the waxy disease of the vessels, as well as froin the increased growth and subsequent contraction of the. fibrous stroma in the cirrhotic form. Symptoms. — 1. Of the infiammfitory form, The leading clinical features of this variety, in BEXGHT'S DISEASE. m addition to the albuminuria which exists in all the forma of Bright's disease, are diminution in the quantity of uiine, and the presence of dropsy. The onset of the disease may be sudden or gradual. Sometimes it is the diminution and alteration of the urine that attracts attention, sometimes the dropsy, sometimes the gastric derangement and general uneasiness ; but which- ever symptom may appear first, the others usually speedily follow. The urine is generally dimi- nished in quantity, often somewhat opaque, and smoky or even bloody. It contains much albu- men and numerous tube-casts. The casts are granular, being composed mostly of epithelium in a state of cloudy swelling ; sometimes bloody ; frequently hyaline or fibrinous. The urea is diminished, it may be, to one-half, one-fourth, or even a less proportion of the naturalamount. This leads to a corresponding reduction of the specific gravity, unless there be a compensatory diminu- tion of water, orincrease of albumen. The dropsy ia generally distinct in the face, and swelling of the eyelids is well marked in the morning. Towards evening, if the patient be out of bed, the legs are chiefly affected. The scrotum and penis are often swollen, and sometimes the abdomen is also dropsical. There is little quickening of pulse or elevation of temperature, but a good deal of gene- ral uneasiness is experienced, with debility and pain in the loins; and dyspeptic symptoms are often present, due to gastric catarrh. Such is the usual condition at the commencement of the disease, and during the period which has been already described as the first stage. But some- . times at this stage a much more serious condition is developed — namely, suppression of urine, fol- lowed by coma or convulsions leading to a fatal result ; or dropsy may increase to such an extent as of itself to cause death. Or, again, without or even with the most unfavourable symptoms, under appropriate treatment the kidneys may begin to act more freely, the urine increasing in amount and improving in characters, with consequent gradual disappearance of the dropsy, and restora- tion of health. Or, as often happens, the general condition improves, but a chronic albuminuria remains, and the disease passes into the second stage. The urine is then no longer bloody ; the quantity is greater, though still below the normal ; the specific gravity is low ; there is albumen, along with tube-casts, fatty, hyaline, or mixed, partly fatty and partly hyaline. The urea is below the normal standard. The dropsy may continue, and may even gradually increase, or it may pass off and only appear when the patient is fatigued, or when he has caught cold. The general symptoms remain unchanged, except that anaemia comes on, and the patient's debility steadily increases. This course of events may pass on to a fatal result; or there may be complete, OP, as is more common, merely partial recovery. In this condition the patient may linger for many months, occasionally suffering exacerbations, and he may succumb to one of them, or to one of the numerous complications to be presently described. If the patient passes into the third stage, he appears prematurely old. His urine is of natural amount or even somewhat increased in quantity, but of low specific gravity. It contains albumen 12 and a few casts, mostly hyaline, with scattered fatty cells imbedded in them. The urea is still diminished. There is dropsy of the feet and anldes in the evenings, and slight exposure brings on more general attacks. The face is pale and pasty, and the eyelids are often oedema- tous. The pulse becomes hard and tense ; the arteries gradually become thickened from sclero- sis and atheroma ; while the apex-beat of the heart passes downwards to the left side, owing to hypertrophjr, particularly of the left ventricle. In this condition a fatal result may be induced by an acute exacerbation with general dropsy ; by chronic, or, more rarely, acute uraemia ; or by intercurrent attacks of inflammatory or other affections of various organs. 2. Of the waxy disease. The onset of this affection ia gradual and insidious. A patient who has suffered from phthisis, syphilis, or other wasting malady passes an excessive quan- tity of urine, and finds himself obliged to rise several times during the night for micturition. The urine is pale, of low specific gravity, containing at first no albumen, subsequently only a trace, ultimately a considerable ■. amount. The urea is little, if at aU, diminished ; the tube- casts are extremely few, and mostly hyaline. There is no dropsy, but evidence of concomitant waxy affections of other organs is frequently afforded. The liver is enlarged, its margin being easily felt and sharply-defined. The spleen is also increased in size. The blood is slightly altered, tho white corpuscles being somewhat increased, and the red being rather flabby and ill-defined. These conditions gradually become more distinct, and the strength of the patient diminishes, partly from the disease of the kidneys and other organs, partly from the wasting diseases which have induced the degene- rative changes. A case of the kind has been known to go on for nearly ten years, during which time the urine continued of the characters just described, and dropsy never appeared. At length the vital powers of the patient became de- pressed,head symptoms gradually supervened, and death ensued. It is not often that such an uncom- plicated casi! is met with. More commonly the exhausting disease which led to the degeneration causes death before the waxy change has gone so far. Sometimes also intercurrent complications induce the fatal result. Clinical observation renders it probable that the kidneys, as well as the liver and spleen, may recover from their degeneration, in cases in which the causal malady has been got rid of. 3. Of the cirrhotic disease. The onset of this affection is extremely insidious, and it may exist for a long time without distinctly manifesting itself by symptoms. Its existence is often dis- covered only when dyspepsia, ursemic convulsions, or blindness from retinitis leads the patient to consult a medical man. The earliest symptoms are occasional slight albuminuria, and frequent calls to micturition during the night, the urine however not being excessive, its specific gravity being low, and the urea somewhat diminished. But when the disease has existed for some time the complexion becomes altered ; the eye assumes a peculiar appearance from ffidema of the conjunctiva ; the patient is subject to dyspeptic l78 BEIGHT'S DISEASE. jttaots; the heart becomes hypertrophied, and the vessels sclerosed and degenerated ; while there is little or no dropsy. When the disease is advanced, these changes in the circulatory organs are -well-Diarked, and the cachectic con- dition becomes distinct. The occurrence of various complications, such as severe gastric catarrh, diarrhoea, anaemia, dyspnoea, bronchitis, cedema of the lungs, headache, ursemia, and the characteristic retinal affection, render the diag- nosis easy. Frequently towards the end there is an increased flow of urine, of low specific gravity. This is in some cases a very prominent symptom. The disease is never recovered from, and the fatal result occurs from ursemia; from some inflammatory complication, such as pleurisy, peri- carditis, bronchitis, or pneumonia ; or from some result of degenerative change, as haemorrhage from a mucous surface or into the brain. Complications — (a) Oonnectod, with the Abdomen and Alimentary System. Gastric affections aremet witn in all the forms of Blight's disease. Catarrh of the stomach — acute, sub-acute, and chronic — is common to them all, and is characterised by an unusual tendency to nausea and vomiting. It is especially frequent during the first stage and in acute exacerbations of the inflammatory form, and is often a chief source of suffering dunng the most advanced stages. It is not uncommon during the whole course of the waxy form, but is most usually met with in the cirrhotic variety. So close indeed is the relation- ship between them, that in the management of cases of cirrhosis regard should constantly be had to the state of the stomach, and in no case of chronic gastric catarrh should the physician neglect to enquire into the state of the urine. This affection, when complicating the early stage of the inflammatory form, often owes its origin to the same cause as the kidney-affection is due to. AVhen complicating the later stages of the inflammatory, and any of the stages of the cir- rhotic disease, the catarrh is probably a result of efforts at elimination of materials retained in the blood by the failure of the action of the kidneys. When occurring in the waxy form, it is frequently due in part to the existence of waxy degeneration of the vessels of the gastric mucous membrane. In the waxy disease we sometimes find blood mingled with the vomited matters, just as we find hsemorrhage occurring in other organs when this degeneration exists. Catarrh of the intestine also occasionally occurs, sometimes producing an exhausting diarrhoea, especially in advanced inflammatory and cirrhotic cases ; but it is along with the waxy disease that intestinal symptoms are most common. These are due to waxy degeneration, and consequent ulceration; or to ordinary tu- bercular disease of the intestine. Both of these affections induce diarrhoea, but there is evidence that not only may it thus occur, but that blood may also be discharged, although there be no ulceration recognisable by the naked eye. Hepatic affections. — Functional derangements of the liver occur in the course of all the forms of Bright's disease, The chief organic changes are fatty degeneration, waxy degeneration, cir- rhosis, and syphilitic affections. The first-named is not specially related to any of the forms. The waxy degeneration and the syphilitic affec- tions are of course commonly met with as aceompaniments of the waxy disease ; whilst cirrhosis attends upon the cirrhotic kidney. Ascites is often seen as a manifestation of general dropsy in the inflammatory form of Bright's disease ; and sometimes this is a pro- minent symptom in mixed forms, when waxy liver is associated Tvith a waxy and slightly in- flammatory condition of the kidneys. Peritonitis is occasionally the cause of death in all theforms of Bright's disease.Itmayresultfrom local affections, or from the state of the blood ; and may be acute, severe,' and therefore obvious, or so insidious as scarcely to attract attention. (;3) Complications connected with the Blood, or with the Iiymphatic- and Blood^ glands. The spleen is usually unaffected in cases of in- flammatory Bright's disease, except such as prove fatal in the earliest stage, and in which the spleen is affected in common with the kidney In the waxy and cirrhotic forms corresponding' lesions are frequent in this organ. > The lymphatic glands are rarely altered ex- cepting in the waxy form, in which they are sometimes the subject of the waxy degeneration, sometimes of tubercular disease, or of strumous inflammation. The hlood itself is altered in its chemical com- position. In the inflammatory form its density is diminished, the corpuscles and albumen being deficient, while the water is correspondingly in- creased. The quantity of urea is above the normal. In long-standing cases of waxy disease similar changes are found ; and not unfreqnently there is a slight numerical increase of the white corpuscles, and flabbiness of the red blood-discs when the spleen is affected. In the cirrhotic form like alterations also occur. Htemorrhoge is apt to occur in advanced stages, especially of the cirrhotic form. It may take place from the kidn eys, or from the mucous mem- branes, particularly that of the nostrils. In the inflammatory affection hsematuria is common in the early stage ; in the waxy variety this symp- tom occasionally occurs, but rarely to a serious extent. (7) Complications affecting the Oiroula" tory system. Hypertrophy of the heart is almost always pre- sent in cases of advanced cirrhotic disease, and also in the advanced stages of the inflammatory affection. One may trace in patients the gradual development of this hypertrophy, advancing yan passu with the progress of the renal affeotioa It is comparatively rare in the waxy form. Hy- droperioardium is met with in somei cases, as a manifestation of general dropsy. Pericariiiia occurs as an intercurrent affection in all the forms, but especially the inflammatory and the cirrhotic; It is apt to be overlooked, owing to the absence of local pain, or from the pain being referred to the abdomen. Endocarditis is also frequently associated with the various forms'of Bright's disease The arteries are sclerosed and atheromatous in the advanced stages of the inflammatory and in the cirrhotic, but not so much in the waxy disease. In that affection the small vessols ia BRIGHT'S DISEASE. 179 ather palts are frequently the seat of waxy de- generation. Thickening of the arteries occurs jonstantly in the more advanced stages of the inflammatory and cirrhotic diseases, and is duo in great part to hypertrophy of their middle coat, in lesser degree to sclerosis of the tunica iutiraa, the tunica adventitia, and perhaps the perivascular lymphatic sheath. The pvJM be- comes tense and sustained in chronic cases, partly from the hypertrophy of the heart, partly from the changes in the capillaries and smaller arteries. (5) Complioatlons connected with the Bespiratory system. Acute bronchitis is common, especially in the advanced stages of Brighc's disease, and tends to pass into the chronic state. Bronchitis may originate also as a sub-acute or chronic afifection. (Edema of the lungs is very common in ad- vanced stages, and frequently occurs as a mani- festation of general dropsy in the early, as well as in the later stages of Bright's disease. It may be very suddenly developed in cirrhotic cases, and may rapidly prove fatal. Pneumonia occurs sometimes as a cause of inflammatory Bright's disease, sometimes as a consequence of exposure to cold during the course of chronic cases. Phthisis in its various forms is found causally associated with these renal affections, frequently with the waxy, and more rarely with the inflam- matory form. It usually proves fatal while the renal malady is yet in its early stage. Hydro- thorax, acute or chronic, is often seen in dropsical cases. Pleurisy occasionally occurs with all the forms of Bright's disease, and may be due to the state of the blood ; or, as seems more likely, to increased susceptibility to inflammatory changes, which results from the lowered vitality of the organism. Dyspnoea is frequently met with in the inflamma,tory and cirrhotic forms of the dis- ease, and may be independent of any local lesion, being probably a result of uremic poison- ing. (Edema glottidia is apt to occur in inflam- matory cases, when even a slight laryngitis has &om any cause been brought on. (e) Complications affecting the Skin and SabcutaneouB tissues. Dropsy, in the form of anasarca, is almost constantly present in the early stage, and during exacerbations of the inflammatory form. It can scarcely be said to occur in uncomplicated waxy and cirrhotic cases. Eczema is occasionally troublesome in chronic cases. Erysipelas is met with now and then, always constituting a serious addition to the other malady. (C) Complications affecting the TTrinaTy organs. The chief of these is scrofulous disease of the kidney, and more rarely of the bladder and prostate. They occasionally occur along with the waxy aflection. (ri) Complications affecting the Nervous system and Special senses, Urremio blindness may occur, which is sudden and usually temporary, being unaccompanied by any lesion 'recognisable by the ophthalmoscope. It is generally met with in advanced cirrhotic and inflammatory cases. Betinitis albuminurica is a peculiar and characteristic inflammation of the connective tissue of the retina, leading to the formation of white patches and lines, with fatty degeneration. With it are also frequently associated minute haemorrhages into the sub- stance of the retina. This occurs by far the most frequently in cirrhosis. It is often also seen in the advanced stages of the inflammatory form, and is rarely recovered from except in the case of pregnant women, in whom it seems apt to occur as a passing condition. Vrtsmta includes a group of the most strik- ing symptoms of Bright's disease. It may occur at the commencement of the acute inflammatory affection, or in its later stages, or in the chronic forms. The condition is, however, rare in the purely waxy disease, but common in the cirrhotic. There are several types of nrsemia, of which the most important are : — (a) Sudden acute convul- sions, followed by coma and death ; (i) Gradually advancing torpor, passing at last into coma. The clinical features of these and minor varie- ties are described, and the hypotheses as to their origin discussed, in the article Uraemia. Headache is frequently complained of by patients snflTering from Bright's disease. Apo- plexy from hemorrhage into the substance of the brain is common in the later stages of the in- flammatory and cirrhotic diseases. It is due partly to the degenerated state of the vessels, and partly to the increased pressure resulting from cardiac hypertrophy. (6) Complications affecting the Iiooomo- tory system. Of these the only ones of importance are disease of bone, which has been already referred to as a causal complication in waxy cases ; and gouty affections, which have been mentioned in connexion with the cirrhotic disease. ' • Diagnosis, (o) Of Bright's Disease from other affections. From massive congestion of the kidmeys due to cardiac disease these maladies are distinguished by the general condition of the patient ; the absence of cardiac disease, and of congestion in other organs ; and the characters of the urine. In heart-affections the urine is generally scanty, high-coloured, not of low speci- flc gravity. It may contain albumin, and deposits urates, but rarely blood, renal epithelium or lube- casts. Hyaline casts may be present, but never in any large quantity. The presence of epithelial and fatty casts, or marked diminution uf the amount of urea in any case, proves at least the co-existence of actual inflammation of the kidney. From paroxysmal hiematinuria and albumin nuna, Bright's diseases are distinguished by the abrupt commencement and brief duration of these maladies ; by the marked nervous symp toms, with gastric catarrh, and sometimes slight jaundice; and by the absence of dropsy. In haematinuria also the condition of the urine is very distinctive ; the dark-red colom being due, not to blood-corpuscles, but to granular pigment, the deposit consisting mostly of this material and of hyaline casts. In paroxysmal albuminuria again the amount ot albumin is very large, and the number of tube-casts extraordinary. Hrt and hacking, constant, incessaut, and in one case the sound resembled that made by the cough of a sheep. 2. Pain is, in regard to the frequency of its occurrence, the next symptom recorded. It was mentioned as being present in 22 cases. The seat of pain was almost constantly referred to the situation of the fourth and fifth dorsal vertebrae at one or both sides of the spinal column. The pain was mentioned in a few cases as existing only in front, beneath and at one oi both sides of the upper end of the sternum and below the clavicles. The feeling was de- scribed in some cases (5) as of distressing tight- ness, and in one cjise as a ' spasm.' Tenderness on pressure over the seat of pain was very fre- quently observed. The persistence, of the pain was very varied. 3. T>ifficulty of breathing was a noticeable symptom in several cases. In 13 it was recorded as being specially so ; in 4 it had all the charac- ters of spasmodic asthma, occurring at intervals and especially during the night. 4. IHfficulty of swallowing was noticed in 10 cases ; in one of these the difficulty was remarked, especially in swallowing liquids. 5. Hainoptysis was present in 10 cases. Tlio amount of blood varied in these cases frcn BEONCHIAL GLANDS, DISEASES OF. 193 nmrked streaks to copious expectoration, lasting two or three days. No case was recorded as presenting tliis symptom except on tplerably clear proof that it depended on bronchial gland enlargement, and on no other cause. 6. Congestion and puffiness of the face have been mentioned as present in 3 cases. 7. Expeciaration of mucus, such as results from bronchial catarrh, was frequently present. Expectoration of pus was present in 8 cases. In each it resembled the contents of an ordi- nary glandular abscess mixed with air. In one of these the discharge was intermittent. The frequent occurrence of cough without any ex- pectoration was remarked in many cases. Cal- careous particles are mentioned also as having been expectorated. 8. Loss of voice (4 cases) and hoarseness (2 cases) are recorded as striking symptoms. 9. Vomiting is mentioned as having been present twice. 10. Lastly, the position assumed with least discomfort by the patient when in bed was noticed in 41 cases. Of these 23 rested on that side on which the glands were mentioned as being chiefly if not wholly affected. In 16 cases an opposite condition was noticed. In 2 cases lying on the back was the most comfortable position. One patient, unable to lie down, sat when in bed, and stooped forward. One patient, a little boy, could only rest on his face and knees. This case was further remarkable in reference to the clearness . with which the disease was recognised and the successful result of subse- quent treatment. It might be mentioned here incidentally that the glands of the right side were noticed as being chiefly affected in 28 cases, and of the left in 22 cases — in 4 both sides seemed equally affected, and in 4 no record was made. Tlie general or constitutional symptoms connected with the malady under notice need not bo discussed here. They are in nowise peculiar, and will be found discussed elsewhere. The symptoms described above have special reference to the bronchial glands. The cough and its peculiar character- istics are, no doubt, in a g^eat measure depen- dent on pressure or on irritation communicated to the pnenmogastric nerves and theii br-inehes. So likewise pain and difficulty of breathing, in a great degreey through direct pressure on the air- passages, may also cause or aggravate these symptoms. Aphonia especially seems to have relation to the condition of the recurrent nerves. In one of the cases which the writer saw with Mr. Lennox Browne, paralysis of the left chorda vocalis existed. The diagnosis of glandular disease was clear, a conclusion confirmed by the results of treatment. Vomiting is mentioned in two cases. M. de Mussy says that this is a more frequent result when the left pneumogastric nerve is pressed upon. He sees a connexion between the troublesome vomiting which occurs in some cases of tubercular disease of the lungs wita like pressure upon nerves. The pujGBness of the face and eyes noticed in these cases is due to the pressure on the venous trunks, a con- dition which also accounts not only for hsemop- tysis, but for bleeding from the nose, occasionally present. Copious and sometimes persistent 13 haemoptysis has been traced to the perforation of a vessel (ulceration in connexion with disease of the glands). Thb Phtsical Signs noticed in the 68 cases referred to were: 1. Dulness. — It was present in 47 cases. It was found between the majgin of the scapula and the spinal column at one or both sides, on a level with the fourth and fifth dorsal Tertebrce. It varied in degree, and was mora readily manifested when the muscles of the back were made tense by folding the arms across the chest, and was often strikingly distinct when one side was contrasted with the other. Dulness was present in front in 8 cases (whether coinciden- tally with dulness at the back or not is not clearly stated), beneath the top of the sternum and at each side below the sterno-clavicular junction. The dulness here was best elicited by the patient holding the head backwards whilst percussion was being made. 2. Flattening of the affected side in front was mentioned in 3 cases. Diminished mobility of the affected side, independent of flattening, was re- corded in 4 cases. Prominence in front was not recorded in any case, though, no doubt, it occurs sometimes. 3. The respiratory somids were variously modi- fied. Marked tubmarbreaihing was recorded as being present over the seat of disease in 14 cases. In 10 the expiratory miirmur was described as being very loud, various modifications of the in- spiratory murmur being found at the same time. Feebleness of the respiratory murmur as a whole was noticed in 14 cases. In some this deficiency extended over the whole lung ; in others it ex- isted over the upper or lower portion of a lung, behind or in front. The observations made on the voice by the writer were few, but M. de Mussy and M. LerebouUet speak of a peculiar and increased reverberation of both the voice and the cough. Dr. Eustace Smith has described in the cases of children a venous hum, heard at the root of the neck when the head is thrown back,' caused by the pressure of tho enlarged glands on the venous trunks. Diagnosis. — In the present article those cases are not kept in view in which the bronchial glands becoming the seat of constitutional disease in association with other glands in the neigh- bourhood, constitute large and manifest tumours — such will be found described under another head [see I^itkathohacio Tcmoues). Nor has it been intended to give prominent consideration to the state of the glands when they enlarge in acute disease — such as eruptive fevers ; nor in those diseases — such as typhoid — where the glands play a secondary part. The writer has been anxious to describe and to assist in recog- nising the presence of a condition in which the disease of the bronchial glands constitutes to some extent a disease per se, or gives rise to complications which it is inaportant to dis- criminate. He believes' the symptoms and signs above described will suffice for the purpose, always remembering that in the present and in allsimilar instances it is necessary to take means for excluding in' our investigations dis- eases which may produce like phenomena. Thus we may find cougli, pain, tenderness on pressure, and aphonia in a case of hysteria without any 194 BRONCHIAXi GLANDS, DISEASES OF. evident structural disease. On tlie otlier hand a small tnmour, say, a small aneurism, may pro- duce all the signs of pressure which are above given as the signs of bronchial gland-enlarge- meut. It is the duty of the physician to recog- nise these differences and distinctions, to trace them to their origin, and thus establish as far as may be the nature of the disease under inves- tigation. Phosnosis will in this, as in like instances, so entirely depend on the nature of the disease, on its amount and its condition, on its relation to and effects on surrounding organs and textures, that each case must be regarded independently. It would be impossible to discuss them fully here— all that can be said is that the simple enlargements generally yield to treatment and within a reasonable period. Thbatment. — In several cases of morbid gland- enlargement, treatment has proved very effective. These cases would seem to be those of simple chronic enlargement. Many such cases have yielded to the use of iodide of iron in the form of piUs or syrup, and to the external application of a solution of iodine, composed of equal parts of the tincture and the liniment of iodine, between the shoulders. The same treatment has likewise proved very effective in cases in which a syphilitic origin for the disease could be traced. Symptoms such as cough, difficulty of breathing, pain as well as dyspnoea, loss of flesh, strength, &e., will all require more or less suitable treatment. The cough and diflaculty of breathing may in some cases be relieved by simple expectorants or antispasmodics. A useful application when pain is a prominent symptom, is an embrocation composed of equal parts of chloroform, bella- donna liniment, laudanum, and spirits of cam- phor. A couple of drachms of this composition sprinkled on the surface of piline and applied on the painful part for a few minutes, often affords relief. Hypodermic injection of morphia may be required when pain is very severe. Under all circumstances it is necessary to improve the general health by wholesome diet, pure air, and the other conditions which will promote good digestion and elimination from the excreting organs. E. Qttain, M.D. BiBONOHOCELE (Pp6yxos, the throat, and leiiK-n, a tumour). A synonym for goitre. See GOITSB. BKOKCHOPHONT {pp6yxos, the throat, and (puiiii, the voice). The resonance of the voice, as normally heard on auscultation over those parts of the chest which correspond with the main bronchi, and, in certain mordid condi- tions, beyond these situations. Bee Physical EXABIIJTATION. BBONCHO-PBTEXTMOITIA. A synonym for catarrhal pneumonia. See Pkbumonu. BEOWZED SKIH". A peculiar discoloura- tion of the skin frequently associated with Addi- son's disease. See Addison's Disease. ' BBOW-AGTJB. A synonym for frontal neuralgia, or tic-douloureus. See Neuealgia; and TlC-DoDLOTTEEUX. BBtriT. {Sruit, Fr., a noise.) A word used to designate various abnormal sounds heard on BTTBC. auscultation, in connexion with the heart ot vascular system. See Physical Examinatiok, BtTBO {PovPiip, the groin).— Synon. : Apos- tema inguinis ; dragonceUts ; 'Si, Bubon; Ger. Leiaienbeule. Definitiok. — ^An affection mentioned in the most ancient medical writings, but not properly distinguished in its several varieties until the present century. Inflammation of any lymphatic gland, set up by irritation of the surfaoei con- nected with the afferent ducts of that gland, has been called bubo ; but the term is almost ex- clusively confined to swelling of the glands of the groin consequent on venereal irritation of the genitals, and will be so employed here- Vaeieties. — Buboes are divided into : -^l. Simple bubo, known also as sympathetic bubo, due to inflammation of a gland through ordinary irritation from an inflamed surface. 2. Spedfe bubo, (a) The chancrous or virulent 4«4p, or abscess inoculated with the pus of a chancre. (b) The syphilitic bubo, or indolent enlargement of the lymphatic glands accompanying the de- velopment of the initial sore of syphUis. The glands first affected in the sympathetic and in both kinds of specific bubo are always those in most direct communication with the sore. Further, according to Iticord, when chan- crous matter has reached a gland through the absorbent ducts, it never passes beyond that gland into another more remote in the series. On the other hand, the effect of syphilitic ab- sorption is general, and affects tliose remote from, as completely as it does the glands nearest to, the inlet of the poison. Buboes occur most frequently on the side of the body occupied by the source of irritation, still not rarely on both sides, and sometimes only on the side opposite to the position of the ex- citing sore. The crossing of the irritant is due to anastomosis or interlacing of the lymphatics at the mesial line. When bubo forms in both groins, there is usually a. sore at the mesial line or on each side. Bubo, including simple and virulent, occurs in about thirty per cent, of chancres ; how often with urethritis and other lesser venereal affections is not known, 1. Simple Bubo — Adenitis (dSV, a gland). JEiiOLOGY. — This variety may be caused by: — (a) Mechanical irritation of the sur- face ; such as erosions or fissures irritated by dirt or by caustic applications, (b) Urethritis, balano-posthitis, or a chancre when acting as a simple local irritant. Simple bubo is also often excited by herpes, erysipelas, boils, or other non- venereal irritants of the genitals, (o) Lastly, though nearly all buboes can be traced to a lesion of the part where their absorbents arise, there are a very few with which no lesion is present. Such are caused by excessive sexual intercourse or excitement; they are met with generally among young lads and girls. This form has received the names of idiopathic bubo, babon d'emblee. Symptoms. — There are two forms of simple bubo: — 1. Slight swelling and tenderness of one or several glands, ending in a few days by resolution. This occurs most frequently in urethritis, balano-posthitis, or simple chafingli' BUBO. 105 In genuine chancre the next and more serious form is most frequent. 2. Swelling, commonly of one, seldom of seraral glands ; bra-wny thickening of the surrounding tissues ; redness of the in- teguments ; great tenderness and pain, espe- cially when -walking. In a few days this con- dition terminates either by abscess, by gradual subsidence to the normal state, or by chronic induration of one or more glands. When the bubo suppurates, the matter, instead of point- ing at once, may burrow in various directions among the layers of cellular tissue before it breaks through the skin. The pus of this form •A bubo is always the ordinary pus of inflamma- tion. Such cases may terminate by gradual con- version into chronic fistulse, or the glands may degenerate in scrofulous persons by enlargement and suppuration, or there may be successive formation of abscesses around the glands with undermining of the skin. This is most fre- quently seen in persons who have previously had constitutional syphilis, erysipelas, and other septic inflammations. Phoqnosis. — This form of bubo is seldom dangerous, but serious where it terminates in burrowing; it is then often very tedious and ex- hausting to the patient. 2. Speciflo Buboes. — (a) ViruXent bubo. This is in reality an enormous chancre, identical in all but size with the sore whence it was inocu- lated. This form is never met with in gonor- rhoea or in syphilis, being a consequence of the local sore only. It may be generated in two ways. 1. By touching the surface of a simple open bubo with chancrous pus. 2. By absorp- tion of chancrous pus along the lymphatic ducts leading from the chancre to flie gland most directly connected with the sore. Two patho- logical facts prove the reality of this mode of origin. Pirst, occasionally small circumscribed abscesses form in the course of the lymphatic ducts before they reach the gland. These little abscesses when opened present the peculiar cha- racters of the chancre. Secondly, until the necros- ing action has laid open the interior of the lym- phatic gland nearest the original chancre, the abscess about the gland retains its ordinary phlegmonous character. The conditions which assist or hinder the con- veyance of chancrous pus along the lymphatic vessels are wholly unknown. The proportional frequency of virulent bubo to the number of chancres is not known. It is far less frequent than simple bubo. It is said that women suffer more rarely than men in pro- portion. When not accidentally inoculated,- virulent buboes are .almost wholly confined to the groin, and originate in the gland which lies commonly in the centre of the group over the great blood- vessel.1. Occasionally with chancre on the finger, the epitrochlear or axillary glands de- velop into . virulent bubo. Hiibbenet of Kiew experimentally inoculated a soft chancre on the cheek, which was followed by virulent bubo of the gland in front of the tragus of the ear. This bubo is generally unilateral; rarely are both sides of the body affected ; in such cases tile chancre is usually at the mesial line, or there aro two chancres. Still more rarely the bubo forms at the side of the body opposite to that of the chancre. The time for appearance is generally in the first or second week of the existence of the chancre ; but it may occur at any time while the chancre is spreading. SYMrroMS. — ^At first the symptoms of specifie bubo are those of acute abscess forming rapidly round a single gland. Thus far they differ nowise from those of simple bubo. When the contagious pus reaches the abscess accidentally from without, or from within the gland by ulcera- tion or incision of its capsule, the simple suppu- rating cavity becomes a spreading ulcer, which rapidly makes itself widely open by destruction of the integuments. The skm, thin as tissue paper, gives way at several points, and lets out a large amount of matter, which is thin, yel- lowish-grey or yellowish-red, with shreds of a chocolate colour floating in it. When perforated, the skin breaks rapidly away until the cavity is widely exposed. The further progress varies. In the least severe variety the edges of the skin ulcerate irregularly for a short distance, then thicken and begin to granulate ; the fioor of the ulcer loses its unevenness and rises up to the level of the skin, and cicatrisation follows. But commonly a much greater destruction of tissue is effected. The skin is eaten away into wide gaps ; the floor burrows under the skin in long, channels, or dives deeply among the great vessels. , In other cases serpiginous ulceration produces a large shallow sore. The contagious condition of these buboes often continues for weeks or months; so that consecutive inoculation of the skin is not infrequent. The characters of the fully formed virulent bubo are those of the chancre. The surface is greyish-brown, dug-out, ' worm-eaten ; ' the borders at some parts are thickened, everted, and pared away, at others sharply eroded or undermined and curled in. The matter is thin, shreddy, plentiful, reddish in colour, and inocul- able. Again like the cliancre, the virulent bubo passes tlu:ough periods of extension, stagnation, and repair. The last stage is often long post- poned by phagedana, a characteristic of no other bnbo, but another mark of kinship to the chancre. Phagedaena very rarely attacks a bubo if it at- tacks the original sore. The virulent as well as the simple bubo is liable to erysipelas and in- flammatory sloughing. The dwration of virulent bubo for the reason stated is wholly indefinite — ^in a few cases end- ing in a week, in many lasting for months or even several years. Phagedana. — The form of the sloughing in pha- gedaena ismost commonly serpiginous. In this way the bubo may wander over the abdominal wall, the hip, thigh, and perineum, healing here and spread- ing there, or digging deeply among the muscles. Generally proceeding at this imperceptible speed, the phagedenic action may suddenly destroy the tissues with great rapidity for a time, and then pause altogether till anotlier rapid extension is made. In this manner years may pass before healing is complete. Diagnosis. — ^The virulent bubo has in its early stage no distinguishing mark from the simple aouto bubo. After it has become inoculated with 196 the oontagious matter it is distinguished from every other affection by the eharacters already described. The earliest signs of virulence are two ; the matter which escapes when the bubo is lanced is thin and shreddy, and the edges of the cut become in a day or two eroded and partly covered by adherent sloughs. Subse- quently other characters develope and remove all doubt. Nevertheless, in some cases the signs of virnlenee are so feebly marked throughout that the diagnosis remains uncertain. This diifi- culty may be increased by the primary sore having healed before the suppuration of the bubo, or by its being hidden in some unusual position (urethra, anus). Pbognosis. — This is not always grave. Virulent buboes often reach cicatrisation in a few weeks, and meanwhile cause no serious inconvenience. On the other hand, they are prone to inflamma- tion, or to phagedsena, and thus may permanently cripple or even destroy life. (i) Syphilitic Bubo {indolent multiple bubo, plkade ganglionnaire). — This enlargement of the group of lymphatic glands in nearest connection with the initial sore is the constant, or at least almost constant, symptom of early syphilitic in- fection. In this it differs much from the bubo of chancre or gonorrhoea, in which affections the bubo is more often wanting than present. Four conditions have been noted to exist in patients in whom the enlargement of the glands could not be detected, namely, 1. Phagedsena of the sore. 2. Obesity ; in such persons the lym- phatic system as a rule is small. 3. Second infec- tion ; i.e. a primary sore on a patient who has had constitutional disease before. 4. Scantiness of the induration of the primary sore, the sore itself being ill-developed. Buttheseexceptionsaremost rare. Fournier gives five instances only in 265 cases of hard sore, accompanied by well-marked general syphilis ; or 2 per cent. In 176 similar cases noted by the writer, three had no apparent inguinal enlargement. One of the patients was a very fat man, and in another the initial sore was only slightly hardened. The seat of this bubo is, in the great majority of cases, the groin, whither, besides the lym- phatic duets of the external genitals, those of the anus, perinseum, buttocks, and lower part of the abdomen are directed. But the glands of other regions, epitrochlear, axillary, sub-maxil- lary, buccal, cervical, and nuchal are all occa- sionally found primarily enlarged when the syphilitic poison enters the body through the regions whence their absorbent ducts are derived. In the groin the bubo is generally double, that is, the glands are enlarged in both groins, those on the side of the sore being most affected. On the other hand, only those on the same side as the sore, in a few cases, enlarge, and in rare examples only those of the side opposite to that of the sore. This enlargement affects the group widely, for when the deeply-placed glands can be examined they are found to be similarly en- larged along the iliac vessels and lumbar verte- brae. Indeed, in some persons all the lymphatic glands of the body are temporarily increased in size. The enlargement of the glands is first per- ceived about eleven days after the induration of BUBO. the sore, though probably the affection com- mences at the end of the incubation of the poison. In extremely rare instances enlargement is de- layed until the third or fourth week after the induration of the sore. - Symptoms.— The distinguishing marks of this bubo are swelling, wholly devoid of inflamma- tory character, and rarely surpassing an almond or- a hazel nutin size ; gristly hardness ; ready isolation and mobility; insensibility to pressure; natural hue and condition of the overlying skin ; and absence of fulness of the cellular tissue.' The gland in most direct communication with the sore is most enlarged; in rare excep- tions only a single gland is enlarged. Copious enlargement of the glands does not always attend copious induration of the sore, nor is scanty in- duration of the sore always accompanied, by small swelling of the glands, though commonly this is the case. So also, though absence of tenderness is the rule, the glands may be slightly painful it pressed. Again, though the glands remain dis- tinct in most cases, they have been known to coalesce into a single mass, which becomes fixed to the fascia. In many patients the dorsal lymphatic vessel of the penis becomes indurated sufficiently to be easily distinguished under tlie This bubo reaches full development in one or two weeks, and remains without apparent change for several weeks, or even for two or three months. Then it begins to diminish slowly, hut is generally still evident in the fifth or sixth month after, infection, and now and then even for years afterwards. In rare cases the enlarge- ment vanishes in two or three weeks. The long duration of enlargement renders this bubo a valuable sign of constitutional syphilis when the primary sore has disappeared.. Again, the con- spicuous enlargement of a group of glands may indicate the place of entry of the eyphilitic poison when that is hidden. Terminations. — In nearly aU cases the glands revert to their natural state. Now and then suppuration takes place, not from the syphilitic change, but from ordinary irritation, and then produces a simple phlegmonous abscess. _ This is apt to occur in strumous persons. The glands enlarge still more, grow soft, and coalesce; presently matter forms in the thickened cellular tissue around the glands, and the further pro- gress becomes that of scrofula. Diagnosis. — This is generally easily dravn from the character of the swelling., aided by the presence of other sypbilitio signs (hard . sore, rash on the skin, &c.) This bubo may be con- founded with chronic inflammatory enlargement, but in such cases the history and attendant symptoms remove doubt. Prognosis. — Apart from its connexion with syphilis, the prognosis is good. The only un- toward termination is scrofulous degeneration. _ Treatment of Buboes. — 1. The ei/phiUtic bubo hardly needs treatment. It usually causes no trouble, and gets well independently of anti- syphilitie remedies. If tenderness or aching occur, rest and a few warm baths are sufficient. If suppuration take place, the abscess must bs incised and poulticed. The scrofulous degene- ration is best met by anti-scrofulous remedies— BUBO. 197 iodide of ammonium, or of iron, eod-lirer oil, nu- tritious food, sea-air, and other tonics. Mercury, in ^ -grain doses of the bichloride, combined ■with the iodide of sodium or with solution of per- chloride of iron, may be added to the treatment. Locally, the abscesses and sinuses must be emptied as fast as they' form, and cleared by syringing with weak astringent lotions. 2, Simple acute btibo arising from any cause demands the same treatment, namely, that of acute abscess. In the early stages, antiphlogistics '_rest in bed, the constant application of a cream made of equal parts of extract of belladonna and glycerine, warm poultices, fomentations, and baths, sometimes even leeches) are requisite. Caution must be observed in applying leeches if chancre be present. They should be used only in the early stage of congestion, lest the bites be converted by inoculation into chancres. Again, the leeches should be applied at the circum- ference of the swelling, so that they may be removed as far as possible from the centre where pointing is most probable. If suppuration arrive more speedily than was expected, and the bubo prove a virulent one, incision must be postponed as long as possible, and the leech-bites protected by collodion, carbolic lotion, iodoform, or other antiseptics. When active congestion has ceased, the sub- sidence of the glands may be aided by pressure with a pad and spica bandage. Stimulating oint- ments and plasters, iodine, and similar prepara- tions are of doubtful service, and may possibly re-kindle the inilp.m-aiation. When pus has formed, it should be let out by a vertical incision at once. The vrjper drainage of the cavity should be insmred by making the incision long (fin. usually )> and by placing a bit of lint or drainage tube between the edges of the incision during tbo first twenty-four hours. Early evacua- tion reduces undermining of the skin to a mini- mum, and- prevents burrowing. When matter formn at several points, a small incision should be made at each fluctuating point. When free exit has been given to the pus, the groins should be well poulticed for two days, and then dressed with zinc ointment spread under a compress, the bandage of which, slackly applied at first, may be tightened as the swelling subsides. 3. The chancrous bubo, not being distinguish- able during the inflammatory swelling and con- sequent suppuration from ordinary sympathetic bubo, requires the same treatment — calmants and an_ early single incision. ' By early incision the cavity of the abscess, subsequently the chan- trous ulcer, is kept as small as possible ; by a single incision the number of dianores is re- stricted. Occasionally, but only when the ab- scess has already undermined the skin, more than one incision is necessary. Caustics have no advantajge over the knife for opening the abscess, while they make a, larger gap. When the abscess has been opened and the chancrous nature is suspected, it should be well cleared at the time by injections of one part of carbolic acid to eighty of water, 5-10 grains to the ounce of nttrate'Of silver, of tartrated iron, or of some other astringent and disinfectant. This injection may ba repeated three times in the first twenty- fcurhjurs; and constant drainage maintained by a drainage-tube and a compress of Lister's antiseptic gauze or boracic lint. Should these precautions fail to prevent the conversion of the abscess into a chancre^' it must then be dressed as a chancre. It must be sedulously washed by injection twice daily, dried by careful mopping with bits of cotton-wool, and well dusted and packed with iodoform in powder j the whole cavity being loosely filled with peUeta of cotton-wool, and compressed gently with a layer of lint and a bandage. Should this fail, as it sometimes will, caustic may be applied. The camtics most suit- able are the strongest and most penetrating; such as Vienna paste, acid nitrate of mercury, Bicord's paste (powdered charcoal and the strongest oil of vitriol). To apply* the caustic thoroughly the patient should be anesthetised, If the least part of the surface is loft unde- stroyed, that will reinoculate the whole. Com- plete cauterisation is practically very difficult . to accomplish, hence caustics should be reserved for the cases where iodoform, which, is pain- less, fails. Overlapping bands of skin should be divided, that the dressing may be .fairly ap- plied. Fhagedana. — When the ulceration by its ob- stinacy or by its rapidity deserves this title, plan after plan of treatment must be tried till the destruction of- tissue is arrested — caustics being reserved for the last. When the patient's general health is good, the ulceration seldom fails to yield to iodoform, applied thoroughly in the' manner directed. While the nocturnal gnawing pain continues, the patient should be narcotised with opium or other naareotic. The cessation of pain is a signal that the : eroding action has stopped. When iodoform alone is insufficient, the continuous warm hip-bath sel- dom fails. By it pain is at once arrested and healing soon set in motion. As continual im- mersion in a bath becomes extremely irksome in many cases, the phagedasna may be arrested by keeping the patient in water for sixteen hours every day, and allowing the night to be passed in bed — in this interval the wound should be carefully packed with iodoform. When the phagedsena is stopped, the bath may be discon- tinued and iodoform alone used. If the water- bath fail (and such a result has not yet happened during a considerable employment of this method at the Male Lock Hospital), caustics may then be used. The strength of the patient, generally much exhausted, should be restored by tonics, good diet, stimulants, and other general means. Abortive treatment of bubo. — This once fa- vourite method of treating buboes has fallen into disuse as the varieties of bubo have been better understood. The chronically enlarged glands of syphilis have little or no tendency to suppurate, but subside spontaneously if let alone. Others only suppurate when freely irritated, hence the best abortive treatment for suoh,^ is to guard against the increase of irritation, and assuage that which exists by antiphlogistics. In the bubo virulent by absorptiob suppuration is inevitable. Thus, the sympathetic bubo is the only one which can be acted on by abortive treatment. To anti- phlogistics maybe added cov/nter-imitants, hvA these are uncertain in their effect. Those least 198 BTTBO. open to objection are vesicants, and the form most beneficial is repeated ' flying ' blisters. By this means a series of small blisters are produced round about, not over the swelling. Any other plan is most uncertain — painting the part with tincture of iodine, or other mild irritant, is simply waste of time. To enter at length into even a narration of the multitudinous ways in which irritants, vesicants, and even caustics have been employed would occupy much space to little purpose. Compression is of great value for reducing indolent enlargement, or for removing the boggy condition of the groin where several abscesses have formed, with more or less undermining of the skin. It is useless for the syphilitic bubo and mischievous for the virulent bubo. The simplest and most effectual method of applying compression, is by a graduated compress of lint kept firmly in place by a spica bandage of calico, or of elastic tape. For abscesses, careful packing may be added to the compress. Each focus of pus must be laid open, and bridges or tunnels cut across, so that narrow strips of lint soaked in liquor plumhi auhacetatis and lightly pressed between the fingers, to drive out the dripping excess of fluid, may be laid into the hollows and under overhanging borders of skin. The strips must be renewed every day at first, and the cavities well cleared by syringing with water. In a few days, when the discharge is very small, the strips may be left for three or four days un- changed. The first application is painful, but very soon an insensible crust is formed over the ulcerating surface, and fresh applications cause no discomfort. As soon as liealthy granulations are formed, the plugging should be laid aside. Bbbkklet Hiix. BTJIiBAE PARALTSIS. A synonym for glosso-laryngeal paralysis; derived from the pathological relation of the disease with th« bulb or medulla oblongata. See Labio-Glosso- XiABYiraEAL Pabalysis. BUTiIMIA (iSoS, a particle signifying excess ; and Ai/i^f, hunger). Excessive or voracious appetite. See AppirriTB, Disorders of. BITIiIi.a: {Bulla, a bubble). See Bleb. BTTEirS. The morbid effects produced by the direct application of excessive dry heat. See Heat, Effects of. • BTrRS.2Ei M;irCOS.ai, Diseases of.— Bursse mucosae are spaces in the connective, tissue lubri- cated with a small amount of serous fluid, and situated at points exposed to repeated pressure or friction. Structurally they are composed of a layer of condensed cellular tissue, fusing exter- nally with the areolar tissu e of the part, and lined internally with an imperfect layer of flattened endothelial cells, similar to those found in the pleura or peritoneum. Some bursse, as that over the patella, that under the deltoid, those about the great trochanter, and many others, are constantly present ; but new bursse, equally perfect in their structure, may form at any part exposed to abnormal pressure and friction, as over the outer malleolus of a tailor, under an old corn, or over the head of the metacarpal bone BUES.S! MUCOSAE, DISEASES OF. of the great toe (bunion). Like the great serous cavities, bursse are indirect communication with the lymphatics, and inflammatory products are consequently absorbed from them with great readiness, often giving rise locally to a diffuse inflammation of the surrounding cellular tissue, closely resembling phlegmonous erysipelas in appearance, and always accompanied by ' higli fever. Bursas are liable to four forms of disease :— 1. Acute inflammation and suppuration — Acute bursitis. — This is usually the result of some more or less violent mechanical injury. It may occur in any bursa, but is most common in the bursa patellse, those about the hip and over the olecranon, and in the small false bursa formed beneath an old corn, or in a bunion. The symptoms are those of acute inflammation gener- ally, but the redness and swelling often extend a remarkable distance up and down the limb. Thus, a drop of pus beneath a corn may causa oedema and redness to the knee. The febrile dis- turbance is usually proportionately severe. About the trochanter the abscess mjty assume a chronic form. TpEATMENT. — Hot fomentations, and the ap- plication of glycerine and extract of belladonna (equal parts), may be of use. It is very impor- tant that pus should be let out early, or it may burrow extensively, especially about the knee. The antiseptic treatment, as recommended by Lister, wiU be found especially useful in the treatment of suppurating bursse. 2. Chronic Bursitis — Dropsy of the bursa consists simply of an accumulation of serous fluid distending a bursa more or less tensely. The wall becomes somewhat thickened and opaque, but is otherwise unchanged. ■- The fluid is dear, straw-coloured, and albuminous in character. The cause of the disease is usually repeated slight mechanical injury, but in some cases it may be due to some of those obscure conditions spoken of as ' rheumatism.' The symptoms are merely those of a collection of fluid in the situa- tion of the bursa, perhaps accompanied by a feelr ing of weakness in the neighbouring joint. There is no pain or tenderness. The commonest form of this disease is the so-called housemaid's knee, but it is not unfrequent in the bursa of the popliteal space. Tbeatuent. — Avoidance of the mechanical in- jury, whatever it may be. which has caused the disease, is most important. The swelling may be painted with tincture of iodine twice a day for some weeks, or a series of small blisters ap- plied over it. If this fail, a seton may be passed through and left in for a few days. Or an in- cision may be made into the swelling under anti- septic precautions, and a small drainage-tube introduced for a week or ten days. But before either of these means is adopted, care must be taken to ascertain that the bursa does not communicate in any way with the neighbouring joint. In the ham it is safer never to operate in any case, except perhaps by means of tie aspirator. 3. Chronic enlargement of the bursa, with fibroid thickening of its walla. — This affec- tion is most common in the bursa patellse, but may occur in that situated over tlie tuberosity of BtlESiE MUCOSjE, diseases OF. the ischium. The bursa becomes converted into a dense fibroid mass of almost cartilaginous hard- ness. On section it is found to ba composed of concentric layers of dense fibroid tissue. _ There is usually a small central cavity containing a little fluid. The cause of this change, as of simple dropsy, is repeated mechanical injury of a slight nature. The only treatment is removal by the knife. 4, Chronic enlargement of the huraa, with the presence Ju it of the so-called melon-seed bodies. — In this form of disease. CiEOUM, DISEASES OF. 193 in addition to some thickening of the wall and accumulation of fluid in the brasa, small oval, flattish, smooth bodies of a white colour are found floating freely in its interior. These are similar in nature to those found in some forms of ganglion {see Ganohon). This condition is recognised by the peculiar soft crackling feeling perceived on palpation, combined -with the ordinary symptoms of an. enlarged bursa. Mabocs Beck. BTTXTOH in Derbyshire. Simple thermal ■waters. See Mineral Wateb* c OACHEXIA(KaKbs,bad, and ?|ij,ahabit or constitution of body). Synon. ; Fr. Cachexie. Get, Kachexie. DEFnnTioN.-^A chronic state of ill-health associated with impoverished or depraved blood, arising from mal-nutrition, persistent loss of blood-elements, or the presenceof a morbific agent. In such diseases as tabes mesenterica, lympha- denoma, and the like, the patients become cachec- tic from direct depravation of the blood, in consequence of disease of organs which are impor- tantly concerned in its nutrition and elaboration. In other diseases persistent loss of blood- elements arising from chronic suppuration or from repeated haemorrhages (especially observed in some uterine conditions) induces a cachexia which is well described by the term secondary musmia. Again certain poisons introduced from without or nurtured within the body may produce marked cachexia. The syphilitic and malarial poisons are good examples of the first kind. Of cacbexise produced by the presence of morbific agents which have been generated within the body we may instance those arising from defective elimination, as the ursemic and gouty cachexiee from defective functional activity of the kidneys and liver. In the latter connexion it should be noted that, as has been hinted by Sir James Paget in reference to cancer, the malignant cachexia may arise from blood-contamination with the waste products yielded by the morbid growth in the process of its nutrition ; such a growth not only abstracting material from the blood for its nutri- tion, but also contributing effete material to it. It must be further observed that in the opinion of some of the best pathologists the t«rra cachexia implies much more than the secondary ansemia consequent upon the ravages of a given local or general disease upon the system. It rather signi- fies the morbid constitution which is the disease, and which may precede its local manifestation. Thus we may have the cancerous cachexia, culmi- nating in Bcirrhus of the breast, the tubercular cachexia in pulmonary tuberculosis, and the like. It is thus evident that with many observers the terms cachexia and constitutional disease have the same significance. E. Douglas Powell. CACOFIjASTIG (KOttbj, bad, and vXAaau, 1 mould or form). — A term applied to products of inflammation which are more or less incapable of organisation. OADAVBEIO {cadaver, a dead body). — This word signifies ' belonging to the dead body ; ' and it is applied to the aspect, colour, odour, and other phenomena resembling those of death which are sometimes observed in the living subject. CSICTTM, Diseases of. — The structural pecu- liarities and anatomical relations of the csecum are specially fevourable to the occurrence of the diseases to which this part of the large in- testine is most liable, viz., (1) accumulation of the solid and gaseous contents of the alimentary canal, and (2) inflammation. I. Accumulations. — Hardened faeces, biliary and intestinal concretions, foreign bodies, stones of fruit, balls of worms, lumbrici, and gases re- sulting fi:om decomposition, are apt to collect in the CEBCum, and cause varying degrees of local disturbance. Sometimes, as in elderly patients of torpid habit, the caecum is found loaded with faeces, without inducing pain or other signs of inflammation. The right iliac region may be full and hard, and in it may be felt a well- defined, almost painless, doughy mass ; the tu- mour is of the shape of the caecum. As a rule, however, sooner or later the accumulation leads to one or more of tBe following results : — (a) Obstruction of the bowels. Tliis may be partial, as in the various degrees of constipation ; or complete. "When complete, it may even prove fatal without the caecum or peritoneuiri exhibiting signs of inflammation. On the other hand, general peritonitis supervening, obstruction in the caecum may be quickly obscured; still, liowever, the chief pain and tenderness will be found in the right iliac region. (6) Pressure on adjacent nerves, vessels, or other structures, producing numbness and oedema of the right leg, retrac- tion of the right testicle and other symptoms, (c) Inftammation (typhlitis, peritonitis). It is of clinical importance to bear in mind that the caecum, when overloaded or enlarged, may occupy an unusual position, eg. a site between 200 CjECUM, the right and left iliac regions, or it may rfescend- somewhat into the pelvis and press on the urinary bladder. Tympanitic distension of the caacum is gener- ally associated with some fsecal accumulation or obstruction in the colon or other part of the large intestine {see Flattji.encb). II. Inflammation. — Stnon. : Typhlitis; Fr. TypMUe ; Ger. BUnddarmentzmdung. Definition. — ^Inflammation of the walls of the caecum, liable to terminate in perforative ulceration; in peritonitis, local or general; or in inflammation and suppuration of the cellular tissue behind the caecum (perityphlitis). .SlTiotOQT. — As preciisposing causes may be regarded the anatomical peculiarities of the caecum, favouring the accumulation of solids and gases liable to irritate ; the causes of constipation and retention of fsecal matter, or of inertia of the large intestine ; the period of childhood and adolescence ; and previous attacks of typhilitis. Exciting causes. — Attacks of typhlitis have been ascribed to exposure to cold, to irritating ingesta, unripe fruit, &c. Inflammation of the caecum may form part of an attack of enterocolitis or dysentery. AHATomcAL Chaeactees. — Inasmuch as 'there are no cases on record of acute typhlitis proving fatal, in which post-mortem exaBunaf^ion did not show the existence of perforation of the caecum or appendix,' ' we invariably find serious pathological changes complicating the appear- ances presented by simple inflammation of the walls of the caecum. In aU cases the peritoneum investing the caecum is involved, as indicated by opacity and injection; and generally adhesions exist between folds of the. intestines, in the vicinity of the right iliac fossa. General peritonitis is usually found associated with perforation into the sac of the peritoneum, and the escape into it either of the contents of the caecum, of an abscess in the cellular tissue behind the caecum, or of a circumscribed peritoneal abscess. Symptoms. — Inflammation of the caecum is met with either as part of a more extensive inflammation — e.g. enterocolitis, dysentery; or alone. In the former case its symptoms are merged into those of the more general affec- tion to which it is subsidiary, whil6 in the latter they are special and characteristic. Clinically, two classes of cases may be recognised : — (a) The inflammatioii is of the catarrhal type, does not end in ulceration, pursues a favourable course, and affects children more particularly. Pro- bably it is strictly confined to the mucous lining of the caecum, (b) The inflammation is more severe, is ulcerative, and is apt to terminate in perforation of the walls of the caecum, and to induce tedious or fatal sequelae. It would seem that all the coats of the caecum are rapidly involved. This form of typhlitis is generally observed after the period of childhood. Though typhlitis usually commences somewhat suddenly, most frequently there is a preliminary , history of intestinal derangement, either in the form of obstinate constipation, or of catarrhal diarrhceii alternating with constipation. The ' Meigs and Pepper, Disease! of Chilirm. DISEASES OF. characteristic symptoms are pain, and a tnmoni in the right iliaC' fossa. The pain is continuous, and is increased, by pressure and by movements, such as those in- duced by deep inspiration and coughing. The right iliac region becomes exquisitely tender and tense ; and, to relieve the muscular tension over it, the patient reclines towards the right side, with the thighs drawn up. In typhlitis from retention of faeces in the caecum (Typhlitis stercoralis) there is a well- defined tumour from the first, which may attain a very large size ; while in other cases there is often merely fulness in the early stage, and afterwards a distinct tumour. In all cases the tumour is of the shape of the caecum, is sharply circumscribed, the lower part specially so, while the upper is less distinct, and may be traced into the ascending colon if this part be also inflamed. When the tumour arises from in- flammatory thickening of the walls of tho caecum, it is less dull on percussion than when consisting of faeces. The abdomen is enlarged. Fever is usually Slight or absent. ■, The walls of the caecum failing to contract^ there, is obstinate constipation, with tormina and vomiting. As u rule, in children vomiting does not become fe- culent. In . typhlitis stercoralis intestinal ob- stniction may arise from the accumulation com- pletely blocking the ileo-csecal opening;, then the paroxysms of pain become very severe, and the vomiting urgent and stercoraceous. Not uncommonly inflammation,, though commencing thus in the caecum with chairacteristic symptoms, extends all over the colon (sge Colon, Diseases of);, then constipation will give place to diarrhaa, and tenesmus with muco-sanguinolent evacuations will indicate a similar affection of the sigmoid flexure and the rectum. The attack, having lasted from two or three to ten or twelve days, usually subsides by resolu- tion — the bowels are copiously relieved, the vomiting ceases, and the pain, tenderness, and tumour disappear from the right iliac region. Even symptoms of- intestinal obstruction -which excite much anxiety may terminate thus favour- ably. Not unfrequently, however, the course becomes tedious and dangerous. ■ The accidents most to be feared are : — (1) Phlegmonous inflammation of the cellular tissue behind the. caicum (see Pbeityphutis) ; and (2) peritonitis.; As a rule, inflammation of the peritoneum is confined, to that portion covering the caecum and adjacent structures; it may, however, become general from extension of this local inflammation, but more frequently from the bursting into, it of tho coTt.tents of the caecum, or of an abscess^ Peognosis. — Inasmuch as typhlitis without perforation almost invariably ends in recovery, the prognosis depends on the occurrence of in- flammatory complications and sequelae, and is, therefore, merged in that of perityphlitis. As a rule, perforative ulceration is less common during childhood than after the tenth or fifteenth year. If, notwithstanding the relief of constipation and the cessation of vomiting, the signs of local inflammation persist, ulceration of the caecum, ot the earliest stages of perityphlitis,, may bo sun- pectfl the prin- cipal milk-ducts. . Between the .eentte and /the edge is the greater part of the tumour, on the whole of a pinkish-yellow colour, but notably pink and soft externally, and yellow and hard internaUy. : The surface yields amilky jmce on scraping, and may show some of the following ap- pearances, which are, however, accidental^, round the circumference little masses, of healthy fat may be included, .though this but rarely happens; . "cysts containing giumous grey or red fluid may have formed by the breaking down of the new growth or by haemorrhage; or such a haemorrhage may have resulted in patches of yellow or even black pigmentation. Microscopical appearances, — Without discuss- ing the jnerits of the opposing theories as to the origin of cancer-cells, the following maybe taken as the undoubted microscopical appearances of scirrhus.; the grey outer layer is made up of in- definite smallish round cells, resembling white blood-corpuscles, infiltrated through the tisane into which the growth is spreading, amongst which are scattered a few which have the ap- pearance of epithelial cells. The next or. pink: layer represents full development, and shows fibro-cellular stroma, enclosing large epithelioid cells, and containing a copious supply of vessels. In the third or yellow layer the stromahas he- come fibrous and the cells are undergoing fatty degeneration; and in the inner white centre the cells are,replaced by indefinite masses of gi:aniilar debris, and the stroma consists of firm, and old fibrous tissue.- See figs. 125, 127, and 126; ,i The relation of these appearances to the clini- cal peculiarities of Bcirrhus/is as. follows: the excessive hardness is explained by the great development of fibrous tissue ; the peculiar in- definiteness of the edge, and the tendency to. involve the skin and ulcerate, by the manner of growth ; while the puckering, retraction of the nipple, and indirectly (from the manner in which cutaneous nerves are involved) the prickingiand shooting pains, are due to the contraction or cicatrization of the stroma. To the latter is also due a very important but notgenerally recognized diagnostic character of an early scirrhus, namely, that long before the skin is involved it is seen to be dimpled when gently moved to and froovei the growth. A scirrhus" which has involved' the skin forms a purplish-red,: flattened, and sinning tumour, covered with small veins and tender) to the touch ; the ulc^r which results &om its. break- ing down is ragged, with a hard base and hard irregular undermined edges, and a dirty surface covered by knobby masses of pseudo-granulationB) which have a great tendency to bleed and often slough. As it is often removed it often returns .in the scar. When occurring in the liver it ia ITo face ipagt 201. Cancer. rio. 117. Papilloma of SoEb Palate. Fi9. 118. EplthDlioma o£ Lip. Pio. 113. rdgo oJ KoL'ent moer. M$i i^^^^^^^Sj^^^^ i ^^^ 1 ^^K p^ ^^^M^^^^^ 1 ^r^ Pis. 120. Simple Polypus otEeotnm. D^G.121. Columnar Epithelioma of Intestine. riQ.l£2. Colloid of Breast. Pia. 123. Cancer o( Liver (Sciirho. Pio. 125. Scirrlitia, Infiltrating Pat. encepbaloid). Pig. 127. Soirrlms of Mamma. Fig. 128. Adenoid of Upper FiG. 130. Adeno-'d of Breast (common .Taw (Benign). type). Pig. 130. Ulcerated Ari-noid of ' Pig. ISl. Aflenoirt of Bve»st (epi- Parotid (Malignant). thelial element in exoe=f). Pig. 132. Adenoid of Breast (Adeno-sarcoma). Srawinffs Blmtrating a Series of Tumours of the Epithelial Type. All drawn to the same scale ( X 87 diameters). CAKOEK. 206 %fteT than elsewhere, and the name of scirrho- eucephaloid is often giyen to it. Sea fig. 96. II. Encephaloid. — Encephaloid, medullary, or soft cancer, bo named from its usually brain- like appearance and consistence, is softer and gro-vrs more rapidly, and is more frequently ob- served in internal organs than scirrhus, often in- deed forming enormous intra-abdominxl tumours. Seat. — ^It has hitherto been observed as pri- mary in the salivary and mammary glands, tes- ticle, ovary, and prostate, the thyroid body, and in the mucous membrane of the nose, the liver, and the stomach. It has with some degree of looseness been sometimes called the cancer of childhood by those who consider scirrhus as almost peculiar to old age. Na&m-eye appearances. — To the naked eye a fresh section usually presents a convex surface ; it is whitish, but generally mottled by coloured patches, the result of old or recent hemorrhages, and yields very copiously a milky juice on scraping. Microscopical appearances. — Encephaloid can- cer differs from scirrhus only in the relative pro- portions of the two chief factors. The cells are more numerous and are contained in larger spaces ; they are sometimes small, but gener^ly much larger than in scirrhus; and the stroma is delicate and fibro-cellular and very small in amount. See fig. 124 Its method of extension is the same as that of other members of the class. It is by far ■the most malignant form of cancer, because of its rate of growth and recurrence, and the rapidity with which it causes general cachexia. Epithelioma. — ^Lobular epithelioma, epi- thelial cancer, or cancroid, develops in con- nection with skin and mucous membrane, and though consisting essentially of squamous epi- thelium, may start from a part which is covered by the cylindrical variety. It occurs near the natural orifices of the mucous tracts — as, for example, on the mouth and tongue, anus, penis, or vulva ; but also at other parts of the skin — as on the acrotum (chimney-sweep's cancer) and at the upper end of the cesophaguS. The his- tory of a local irritation is often obtainable, but more frequently nothing of the kind can be discovered. Naked-eye appearances. — The first appearance is that of a pimple, which soon breaks down in the centre, forming a small sore. When fully developed there is an irregular ulcer with an extensive hard and nodular, generally in- flamed base and circumference; the edges are abrupt or undermined, and the floor grey or reddish, very uneven, discharging a foul pus, and with a groat tendency to bleed. As a rule there is considerable pain, and the proximal lym- phatic glands are very generally enlarged. A section to the naked eye shows a number of minute cylinders of yellowish- white colour, cut sometimes longitudinally, sometimes trans- Yersely,_fusing together into an indefinite mass superficially, but more or less discrete below, and infiltrating amongst the subjacent tissues. On squeezing the section little nodules like sebum appear on the surface. Microscopical appearances. — The cylinders or lobes of epithelioma are found to be made up cf squamous epithelium, which generally exhibits in parts a crenated margin (Max Schultze's spine- cells). A s in the skin, the deeper — that is the cir- cumferential — layer of cells in each lobe, which are the youngest, are roundish or oblong, with large nuclei, and staining readily ; further in, the cells are larger and flatter, and in the centre are found the well-known globes or nests. These were considered at one time as peculiar to epithelioma, but are now known to occur in warts and corns ; they consist of onion-like ar- rangements of epithelial cells, varying much in size and the number of concentric layers, and containing in tho centre sometimes an amorphous mass, sometimes large and irregular cells. The tissues beneath and between the lobules are infiltrated with small cells, and often contain in sections what appear to be iso- lated masses of epithelium ; these are, however, the ends of divided divergent lobules. Opinions differ as to the exact starting-point of an epithe- lioma, the share which the sweat- and other glands talce in it, and also as to the rationale of the formation of the globes. See fig. 118. Epithelioma seems to be more local in its nature than other cancers — that is, a complete and early removal has not unfrequently given the patient a long lease of life. It recurs, as a rule, in the lympathic glands, which inflame and suppurate, and in the scar, and generally proves fatal from the constitutional disturbance it gives rise to. Later but more rarely it may appear in the in- ternal viscera, bones, &c. Cylindrical Epittielioma. — The cylindrical epithelioma — badly named adenoid or glandular cancer^— is speoiaUy the cancer of the alimen- tary mucous membrane, but may occur in the bladder and elsewhere. Naked-eye a/ppearances. — To the naked eye it forms at first a prominent tumour in the interior of-aviscus, which has a tendency like other cancers to ulcerate and involve, surround- ing tissues, so that the mass may reach an enormous size, and may even make its appear- ance through the skin. To the naked eye a section is generally whitish and has a granular appearance, which is given to it by the tubules of which it is made. It frequently causes death by obstruction of the bowel, but if it last sufficiently long, it recurs unaltered in the lymphatic glands, and then in the viscera and other parts of the body. It is not unfrequent to find recurrences in the liver with little if any implication of lymphatic glands. Microscopical appearances. — Cylindrical epi- thelioma consists essentially of irregular tubules lined with columnar epithelium in one or more layers, which are the much overgrown crypts of Lieberkiihn, and differ in microscopical structure from simple papilloma of the digestive tract only in the greater irregularity of the cells and in the larger proportion of connective-tissue stroma between the tubes. See fig. 121. Colloid. — Colloid, or alveolar cancer, named from its jelly-like appearance, has given rise to much discussion in reference to the ques- tion whether it is developed originally in its mature form, or whether it results from tho degeneration, of one of the classes of cancer 1 described above. The latter view is that moet ^C6 CANCER, widely held, though It must be allowed that epithelioma seldom degenerates in this way, and also that the coUoid change usually takes place pari passu with the growth of the tumour. Seat. — Colloid cancer is found most frequently in the abdominal viscera and peritoneum, but may occur elsewhere, as in the breast. Its malignancy is great, but is shown chiefly by the rapidity with which it involves surrounding tissues ; it thus forms primary tumours of enor- mous size, but as a secondary growth is less common ; it does, however, occur in lymphatic glands and other parts. It causes death in most cases by interference with the functions of the organs attacked. Naked-eye appearances. — Colloid cancer con- sists to the naked eye of a mass of semi-trans- parent jelly, varying slightly in colour, but mostly pale yellow : this is intersected by deli- cate white fibrous bands, forming alveolar spaces of different sizes, visible to the naked eye. The consistence of the growth depends upon the rela/- tive proportions of these two constituents. Microscopical appearances. — The bands are found to be actually fibrous ; the contained jelly is arranged in concentric laminae between which are minute granules, and in the centre of which is a granular mass, sometimes quite indefinite, but often showing clearly that it consists of the remains of altered cells. These cells are seen in the more recent parts of the growth to be the subjects of colloid degeneration. The source of the colloid material must be considered still undecided; that some of it is formed by the cells is certain, but it is not equally clear whether the stroma takes any share in its depo- sition. See fig. 122. CoNOtusroN. — Our knowledge of the pathology of new growths is undergoing a process of rapid evolution. While, therefore, the writer has endeavoured in this article, and in that on Tumours, to represent the opinions most widely accepted at the present day, he is conscious that in a very short time these opinions may require considerable modification. B. J. Gocleb. CAITCBITK OBIS (^Canomm, a sore; and oris, of the mouth). SraoN. : G-angrenous Stomatitis ; Noma ; Pr. le Nome ; Ger. Wasssr- Definition. — A phagedsenic ulceration of the cheek and lip, rapidly proceeding to sloughing. Mtioloqy. — Cancrum oris is usually seen in delicate, ill-fed, ill-tended children ; and in these subjects it is commonly a sequela to one of the eruptive fevers. Pormerly it ased some- times to be due to excessive doses of mercury. Symptoms. — The disease commences by swel- ling and tenderness near the angle of the mouth, and if at this stage the mucous membrane is exa- mined, it will usually be found that there is some superficial ulceration on the inside of the lip or cheek — that is, ulcerative stomatitis. From this slight beginning the disease rapidly advances. The soft tissues become much swollen, brawny, shining, and red. Presently a livid spot makes its appearance in the centre, and the surround- ingpart becomes purplish or mottled. If the patient can open his mouth sufficiently to give a view of the gums, they will be seen to be CAPILLARIES, DISEASES OF. red, congested, spongy, and bathed with a profuss and fcetid saliva. The livid tissues of the cheek rapidly slough, the disease perhaps involving the lip, or spreading to the gum, laying bare the alveolar processes, and loosening the teeth. This local aflfection is attended by a high degree of pyrexia, and by great prostration. The disease is very fatal. Rilliet and Bar- thez state that not more than one in twenty cases recover. TjjKiTMENT. — This consists in the application of strong nitric acid to any points where the ulceration and sloughing are spreading. Poultices should be kept constandy on the cheek, and from time to time the sore should be syringed with a disinfecting lotion. The constitutional treat- ment consists in the administration of a full amount of beef-tea, milk, eggs, &e., with a moderate allowance of alcoholic stimulants, as well as bark, ammonia, and other suitable tonics. Begular and systematic administration of food and medicine is of the utmost importance ; and if the patient is unable to swallow, nutritious enemata must be used regularly. W. Faiklie Clakke. CANITIES {camts, hoary or greyhaired).— Whiteness or greyness of the hair. See Haie, Diseases of. OANHES in France, on the Meditep- raaean coast. A dry, bracing, fairly mild winter climate. Exposed to N.W. Abundant accom- modation, both near and at some distance from the sea, CAITTHAKIDES, Poisoning by. See Appendix. CAPE OP GOOD HOPE.— A warm, generally dry climate, but very variable, and liable to sudden storms. Living dear, and loco- motion difficult. OAPILLABIES, Diseases of.— The mor- bid conditions of the capillaries may be described in the following order : — 1. Fatty Degeneration. 2. Calcareous Degeneration. 3. Albuminoid Degeneration. 4. Pigmentation, 5. Changes in Inflammation. 6. Dilatation. 7. Narrowing and Obliteration. 8. Thrombosis. 9. Embolism. 10. Rupture. 11. The New Formation of CapiU Isiries. 12. Capillaries in New Growths and Tubercle. 13. Changes in the Perivascular Spa«9 and Sheath. 14. Teleangiectasis. 1. Patty Degeneration is the most common disease of the capillary-wall, and is frequently associated with fatty degeneration of the sur- rounding tissues. The cause of this change in the protoplasm of the capillary is, as elsewher?, interference with nutrition, and especially wii oxidation. It is accordingly found in morbid conditions of the blood; in interference with the blood-supply; and in lesions of the nervous system. The microscopical characters of the early stages of fatty degeneration when it affects the capilla- ries are not peculiar; in advanced stages the diseased vessels may present the appearance of opaque granular cords ; and the lymphatic sheaths of the cerebral capillaries are sometimes found, under such circumstances, filled with oil-globules and fatty cells. A frequent termination of the disease is rupture and haemorrhage. Fattv CAPILLARIES, DISEASES OF. degeneiation of the capillaries occurs most fre- quently in the nervous centies, in the kidneys, in certain tumours, and in the products of infarction and inflammation, 2. Caloaieous Degeneration, is rare in capillaries. 3. Albuminoid Degeneration affects the Malpighian glomeruli in the early stage of albuminoid disease of the Iddneys. In other parts of the body the capillaries are less subject to albuminoid change than the small arteries. 4. Pigmentation. — Pigmentary granules may sometimes be found in the walls of capillaries, but they more frequently occupy the perivascular space. In either situation pigmentation is the result of chronic congestion or inflammation, or of haemorrhage. 5. Changes in Infianmiation. — The changes of the capillaries of an inflamed part constitute an important factor of the process of inflamma- tion. See Imfiamuation. 6. Dilatation of capillaries, irhich is one of the changes in inflammation just referred to, may become permanent if the process be chronic. Changes in the nutrition of the capillary-wall, combined with disturbances of the circulation, such as increased pressure, produce local dilata- tion or Aneurism of the vessels and subsequent rupture. This is one form of miliary aneurism as it occurs in the brain. 7. ITarrowing and Obliteration. — Narrow- ing of capillaries may be temporary, as in in- flammation; or permanent, from external pres- sure, or from interference with the blood-supply. Karrowing may proceed to complete obliteration. 8. Q'hrombosia commonly occurs in capil- laries as a consequence of embolism or of throm- bosis in the associated arteries or veins. Less frequently the coagulation of blood is primary, and is due to one or more of the usual causes of thrombosis, namely, feebleness of the circulation and alteration of tie blood. 9. Smbolism. — ^The phenomena of ordinary embolism in a great measure aifect the capillaries corresponding with the obstructed artery. But besides this change, capillaries are themselves subject to embolism, or impaction of particles within them. The products of inflammation or degeneration, pigment-particles, oil or fat drops from the marrow of fractured bones, organisms, and various substances artificially introduced into .the circulation, have been discovered ob- structing the capillaries in different instances. All the possible results of embolis'n in large vessels may follow, according to circumstances ; and in the cajse of the cerebral vessels definite symptoms are believed by some to result, such as delirium and choreic movements. See CHOIiEA. 10. Eupture. — Three circumstances specially determine the occurrence of this lesion of capil- laries, namely, disease of the vessel-wall, increase of the blood-pressure, and a ' terminal ' distri- bution of the branches of the artery that supplies them. The most common diseases of the wall are fatty degeneration and aneurism. The blood-pressure rises within the capillaries of any part in ventricular hypertrophy, in increased tension of the arteries of other parts, and in ve- nous obstruction. When an artery is ' terminal,' OAEBONIC ACID. 207 that is, unprovided with other anastomoses than through its capillaries, no lateral relief can be afforded in sudden and excessive rises in the forcB of the circulation. For these several reasons, rupture of capillaries is most frequent when the vessel-walls have been weakened in the fatty degeneration of senile decay, in septic- aemia, inflammation, purpura, fever, and scurvy ; in chronic Blight's Disease, with increased blood- pressure; and in such organs as the corpus striatum, retina, spleen, kidney, villi, and skin. Disturbances in the pressure of the air within the chest powerfully influence the occurrence of capillary-rupture in the respiratory tract, When a capillary-wall gives way, the blood is extrava- sated either on a free surface, constituting hsemor- hage ; into the substance of the tissues aroimd ; or along the lymphatic sheath of the ruptured vessel, where it gives rise to the appearance that has been described as cUsMcting capillary aneurism, 11. ITew Formation of Capillaries. — Capil- laries grow or develop in nearly all forms of new growth, whether inflammatory or otherwise. The young capillaries are derived either from cellular buds upon previous capillaries, which become hollowed by the blood-pressure; irom anastomosing exudation-cells, or ponuective- tissue corpuscles; or, in some cases, from the parallel disposition of exudation-cells. 12. Capillaries in New QTOwtha and Tubercle. — The capillary-walls are believed to play an important part in the production of certain forms of new growth. See Tomoues and TCBEBOLE. 18. Changes in the Perivascular Space and Sheath. — The perivascular or lymphatic sheath, which probably envelopes all capillaries, is liable to certain morbid conditions, which are chiefly secondary to changes in the vessel within it. Thus the space may become filled with blood from escape of the corpuscles by rupture or otherwise; with leucocytes in inflammation; with oil-globules and fatty corpuscles in degene- ration of the wall; with pigment-particles; or with serum in disturbances of the circula- tion. The calibre of the perivascular canal, which varies inversely with that of the contained capillary, may thus be increased, and present uniform or irregular dilatation. Changes in the outer sheath, or wall of the lymphatic space, have also been observed, in- cluding fatty degeneration of the lining cells and hyaline thickening. 14. Teleangiectasia. — At least one form of vascular tumour consists of a local over-growth of capillaries, which are both enlarged and multi- plied. See TxjMOUBS. J. Mitchell Bbuce. CAPIIiLAKT BEONCHITIS. — Inflam- mation involving the minute bronchial tubes. See Bronchi, Diseases of. CABBOIiIO ACID, Poisoning by. Sea Poisons. CAEBONIC ACID, Poisoning by.— The inhalation of carbonic acid causes injurious or fatal results, according to the length of time and degree of concentration. Carbonic acid accumulates in large quantities, almost undiluted, in pits, cellars, wells, mines (especially after 208 CAEBONIO ACID, explosions, constituting what is called choke- damp), volcanic grottoes, fermenting vats, lime- kilns, &c. A continuous contamination of the atmospheric air -with carbonic acid goes on from the respiration of animals and the combustion of fuel. The gradual exhaustion of oxygen and proportionate accumulation of carbonic acid in iU-rentilated apartments is one of the factors of the evil results of bad ventilation, but not the only one, as other animal exhalations contribute largely to the result. As a rule excess of carbonic acid means cor- responding deficiency of oxygen in the atmo- sphere, and the proportion cannot exceed 10 per cent, without rapidly fatal results ensuing; but much less than this causes injurious, and even the like conseijuences if long inhaled ; and less than 2 per cent, cannot be breathed for any length of • time with impunity. If the amoimt of oxygen be not correspond- ingly diminished, carbonic acid if present in sufficient quantity in the atmosphere respired will still act fatally. Thus Bernard found that a bird died instantaneously in an atanosphere of equal parts of oxygen and carbonic acid, and Snow found that 20 per cent, of carbonic acid in an atmosphere containing the normal proportion of oxygen soqn proved fatal to small animals, and that even 12 per cent, might cause death after a longer interval. Symptoms. — Undiluted carbonic acid is not readily inhaled, as it tends to induce spasm of the glottis, butimmersion in such an atmosphereis rapidly fatal. It seems to act like a narcotic: The patient falls down prostrate and insensible, and death occurs almost immediately.' This effect is seen occasionally when labourers in- cautiously descend an old well, or when miners enter a region filled with choke-damp. Hot unfrequently more than one fall victims, as one goes to see what has happened to the other and meets the same fate. When the carbonic acid is more diluted the symptoms are headache, giddiness, and sense of oppression ; followed by drowsiness, and singing in, the ears ; and passing into a condition of stupor and insensibility, with stertorous breath- ing and muscular prostration, death usually occurring quickly and without convulsions. If the excess of carbonic acid corresponds with deficiency of oxygen, we have in addition to the essentially narcotic effects of carbonic acid, the dyspnoea and other sjrmptoms of asphyxia {see Asphyxia). PosT-MOBTEM APPEAEAN0E3. — These are largely those of asphyxia, viz., a general engorge- ment of the venous system. This is generally seen in the brain, more frequently than in as- phyxia pure and, simple. The blood is dark and fluid. The haemoglobin is completely reduced. Animal heat is said to be retained long after death, and rigidity is well-marked and enduring. Patholooy. — As has abeady been said, carbonic acid does not act merely as a negative asphyxiant by taking the place of oxygen, but has a dis- tinctly toxic narcotic effect. Very frequently in cases of poisoning by carbonic acid there is a combination of asphyxia, essentially due to defect of oxygen, with the narcotic symptoms due to carbonic acid. CAEBONIO OXIDE. Tbeatment. — 1. Prephylaetie. — Cautioa should be exercised in exploring wells, mines, &c., where there is likelihood of the accumula- tion of carbonic acid. The introduction of a lighted candle is a rough and ready test of con- siderable value. The mere fact of a candle continuing to bum in an atmosphere- is no test of its being respirable with impunity, for a candle will burn in an atmosphere containing 10 per cent, of carbonic acid if the. oxygen is present in the normal amount, and the presence of an amount of carbonic oxide sufficient to cause death will not materially affect the flame. If carbonic acid reaches the proportion of 16 per cent, the candle will be extinguished, however. If a candle is extinguished, then certainly the atmosphere cannot be breathed, and therefore the test is of sound practical value. If car- bonic acid does exist it should be expelled by creating a draught of some kind. Thus welU may be swept by some such contrivance as an inverted lunbrellaj and a stream of air can be directed into enclosed spaces. 2. Eestorative. — ^Artificial respiration and its various accessories are needed to restore a person actually in a state of coma from carbonic acid. : This treatment, of course, .is subsequent to instant removal from the impure atmosphere. Pure oxygen should also be administered if at hand. D. Fbkeiee. CABBOlflO OXIDE, Foisoning by.— Carbonic oxide is a much more dangerous agent than carbonic acid, and to it are due many of the effects sometimes ascribed to the latter. Pure carbonic oxide is rarely generated' out of the chemical laboratory, but mixed with other gases carbonic oxide is not uncommon. This is es- pecially the case in the fumes of bumilig charcoU. The carbonic acid of the burning charcoal while passing over the heated embers loses an atom of oxygen, or takes up an atom of carbon, ana is converted into carbonic oxide, which bums with a bluish flame at the top. The toxic action of charcoal vapours is essentially dependent on the carbonic oxide they contain. Usually charcoal fumes contain from 2 to 3 per cent, of carbonic oxide, to 25 of carbonic acid, along with some heavy carbliretted hydrogen. The vapours, how- ever, are still as effective after being passed through lime-water, which fixes the carbonic acid. Poisoning by charcoal vapour is not an un- common form of suicide, more particularly abroad; and many cases have occurred accidentally in this country, from sleeping in rooms in wKich there was no flue for the escape of the fumes of burning charcoal, or into which there has been leakage from stove pipes, &c. Carbonic oxide also exists in coal gas, and constitutes its main danger. It is likewise found in the emanations from brick-kilns. Carbonic oxide is an extremely active poison. Letheby found that '5 per cent, of carbonift oxide in the respiratory medium killed small' birds in three minutes, and that 2 per cent, killed a guinea-pig in two minutes. Many similar experi- ments 'have been performed with similar results. The animals soon become insensible, and die generally without exhibiting comiilsive pheno- mena beyond a few tremors or flutterings. CARBONIC OXIDE. SvMFTOMS. — In man iuhalation of carbonic osiide fur a short time, as Sir H. Davy and others hare proved on themselves, causes headache, pulsation in the temples, giddiness, nausea, and great prostration, tending to drotrsiness and insensibility, death being preceded by a state of complete coma. Usually death occursquietly, but signs of vomiting are frequently observed near those Trho have been poisoned by charcoal fumes. Post-mortem Appeakances. — The specially characteristic appearance of death from carbonic oxide is the cherry-red colour of the blood and internal organs. The, post-mortem hypostasis exhibits a similar bright red tint, frequently in those poisoned 'vrith carbonic oxide the face retains a ruddy hue. The red tint of the blood is due to the compound which carbonic oxide forms with haemoglobin. Carbonic oxide dis- places the oxygen and forms a very stable compound irith the hsemoglobin, not readily broken up, and hence the oxygen-carrying power of the corpuscles is paralysed. In the spectroscc^a carbonic oxide blood exhibits two absorption-bands very similar to those of ordinary blood-colouring matter or oxy-r haemoglobin, but a difference in tJie exact breadth and position of the bands can be made out by means of the mierospectroscope when the two are compared together. Carbonic oxide hsmor gloMn resists reduction in the usual manner, and here again differs from normal blood-colour- ing matter. Hoppe-Seyler gives as an addi- tional test the action of caustic alkalies on car- bonic oxide, and on ordinary hemoglobin. With the latter it causes a green colour when mixed with it on a porcelaan plate, while in the former the colour continues red. Patholoot. -r- Carbonic oxide acts in the manner indicated, viz., by paralysing the blood- corpuscles, as Bernard expresses it, and rendering them unable to take up oxygen. , Hence internal respiration is prevented, and death ensues &om aspnyxia. Tkeatment.-t-As carbonic oxide haemoglobin is a very stable compound, and offers consider- able resistance to displacement by oxygen, though not absolute as was at one time con- sidered , artificial respiration is not likely to be successful by itself. The best treatment is vene- section and transfusion of fresh blood. This method of treatment has proved successful in one or two , instances in which it has been employed. D. Febbibr. CABBTJJTCLB. — Stoon.: Anthrax; Fr. Anthrax; Grez. Karbimkel. Definition.— A specific local inflammation of the subcutaneous areolar tissue, rapidly leading to sloughing of the deeper and mere 'central parts, followed by destruction of the skin ; the whole of the dead tissues finally separating in the form of a slough. MiioioQt. — Carbuncle is a constitutional affection, dependent upon conditions cxf general debility or plethora, and often associated with gouty, or diabetic tendencies. It is more com- monly seen in men than in women ; is rarely met with UAd?r the age of twenty ; and attacks aU ranks of life. Symptoms. — The most usual seat of carr 14 CARBUNCLE. 20(< bunde is the back of the trunk ur neck, but it may occasionally be found in other situations. The affection usudly begins as a painful, hard, slightly elevated, and ill-defined swelling, which gradually increases in extent and assumes a dusky red tmt. A vesicle containing bloody serum soon forms over the most prominent part, and on rupturing discloses several small aper- tures in the subjacent sMn, which give exit to a glutinous purulent discharge. This sieve-like condition of the undermined integument often persists throughout the course of the disease ; occasionally, however, owing to the destruc- tion of the intervening skin, the several aper- tures merge into a single, large, ragged opening, and thus expose the characteristic ash-grey, slimy slough, which separates slowly by suppura- tion, leaving an irregular cavity with deeply undermined edges. The cicatrix left after heal- ing is usually uneven and may be permanently discoloured. In the early stage of the disease, while the inflammatory oedema is still extending, the pa- tient generally complains of a burning, throbbing sensation in the part, which may become intensely painfulj but on the foil exposure of the slough, the pain diminishes, and in the later stages it may cease entirely. When the carbuncle is large, or involves a portion of the scalp, there is usually considerable constitutional disturbance of an asthenic type. Death may then occur from exhaustion, which is sometimes aggravated by free haemorrhage result- ing from incisions ; but the most frequent cause of a fatal termination is pyemia. Diagnosis. — Carbuncle is distinguished from boil by the size and extent of the swelling, and by its tendency to spread ; by the livid tint of the skin, and the early formation in it of more than one aperture ; by the character of the slough, by the severity of the pain, and the marked con- stitutional disturbance ; and finally, by the fact that carbuncle, unlike boil, usually occurs singly. PnoaNosis. — This will depend chiefly upon theage of the patient, and upon the seat and ex- tent of the disease, which proves most dangerous to life when situated or encroaching on the scalp, especially in a person over fifty. The coexistence of albuminuria or chronic saccharine diabetes is always a grave complication. Teeatmbnt. — The canstiiutional treatment and the management of patients with carbuncle are best conducted on general principlesi In ordinary cases the diet should be of good quality and sufficient in quantity, with a moderate allow- ance of stimulants, proportionate to previous habits. Should the patient's strength and the situation of the carbuncle allow him to move about, he need not be confined to his room, and may even be allowed exercise in the open air. In the more severe forms of the disease, the frequent administration of dietetic stimulants and good nourishment in an easily assimilable form is usually necessary. The bowels, if they require it, should bo cleared out by some non- irritating aperient, and the patient put on a course of quinine or bark and the mineral acids. Opium may be required in the earlier stages to relieve the intense sufferings of some patients ; 210 CABBUNCLE. while in the after-course of the dieease, it may be sometimes needed to procure sleep. For loeal treatment see Boils. _ _ For carbuncle of the face, an affection distinct from the Malignant Pustule described by Conti- nental surgeons, tee Fostulb, Malionant, and the article on Boils. Wiuuam A. Mkeedith. OABCINOMA. See Cancer. CABDIAC DISEASES. See Heaet, Diseases of. OARDIALGUA (irctpSia, the heart, and 6.\yos, pain). — ^A synonym for heartburn, originating in a popular impression that this painful sensa- tion, which is situated in the epigastrium, is con- nected with the heart. See HEABTBtmN. CAEDIOGEAPH, The {xipiia, the heart, and ypM^, I write). ,This is an instrument for registering graphically the form of the heart's movements. We owe the invention of the car- diograph to Marey, who_ in his physiological researches on the circulation of the blood, ob- tained by the following means the form of move- ment of each cavity of the heart. He introduced into the auricles and ventricles of a horse, hol- low sounds terminating in elastic ampullae filled with air. The air communicated through the sounds and elastic tubes with terminal ampullae, or tympana covered with elastic membrane, on each of which rested a light lever. The move- ments communicated by the heart to the closed column of air were amplified by the levers and recorded by them on a revolving cylinder. In this way tracings of the forms of movement of each cavity, as well as of the exposed apex-beat itself, were obtained, and an explanation of the several parts of the complex apex-traeing ren- dered possible. The cardiograph used for clinical research is a modification of the above, and con- sists of a hollow cup containing a small spring which can be depressed by means of a screw so as to rest firmly on the chest-wall where the impulse is felt. The cup communicates by means of an elas- tic tube with a tympanum covered with elastic membrane carrying on its surface a lever. When applied to the chest the cup hermetically seals the air column which transmits as waves the motion received by the spring to the lever resting on the tympanum. These movements are re- corded by the end of the lever either on the plate of a sphygmograph or on a revolving cylinder. By means pf this apparatus a very perfect re- presentation of the cardiac movement can be ob- tained, the araricular and ventricular elements traced, and the duration of each measured. The transmission of the motion through an elastic medium like air has been objected to, as liable to modify the tracing by (1) the production of secondary oscillations in the air column ; and by (2) gradual change in the form of motion caused ■by the elasticity of the medium. Practically, however, these objections are not valid, as is shown by the fact that the last of a series of cardiac pulsations is often an exact reproduction of the first, and also by the close resemblance between the tracings obtained in this way and those registered by the sphygmograph, or a modi- fication of it, applied over the . apex-beat. A CAEMINATIVES. cardiogram collected by the instrument descrihed on a healthy person is given in the margin. Two cardiac revolutions are recorded. The several waves may be inter- preted as follows : the wave a, in the line of ascent, corresponds with the early part of the ventri- cular diastole. The wave b co^ responds with the true auricular systole ; from b \,o d the line rio. 4. marks the true impulse caused by the ventricular contraction, the rounding of the heart, and its pressure against the cheSt- waU. The wave c, at the summit of the curre, indicates the closure of the auriculo-ventricnlap valves ; c does not always form the sttmmit of the curve, but occasionally in slower cardiac contractions forms a wave below the summit, The waves between c and d are referred to oscillations produced by the closure of the auriculo-ventricular valves, but are probaMy manufactured by the instrument. The break in the line of descent at e, marks the closure of the Sigmoid valves. In the above cardiogram the period of ventricular contraction is measured by the space between the commencement of the line of ascent after the wave h, to the point d, which marks the termination of the systole.* When the heart is hypertrophied and acting vigorously this termination is often registered as a slight eleva- tion of the trace. The clinical value of the cardiograph has yet to be fully established. It has hitherto beenuseful in showing the relation of prsesystolic murmnr and thrill to the ventricular and auricular con- tractions ; in demonstrating modifications of the form of impulse in adherent pericardium ; in re- cording aconsiderable increase in the wave a anda sudden rising of the trace after a, as signs of aortic insufficiency ; and in the recognition of the re- lation between reduplication of the heart-sounds and respiratory influences. The cardiograph is also of great value in registering the form of movement of pulsating tumours and aneurisms. In its application it is sufficient to hold the instru- ment firmly over the apex-beat and to record the pulsations at the end of expiration, the breath being stopped for a brief interval. Occasionally, when the influence of respiration is to be ob- served, this precaution is of course unnecessary; but it must be borne in mind that the movement of the chest-wall modifies the tracing. Balthazae Fobibe, CAJRDITIS (xipSia, the heart). Inflamma- tion of the substance of the heart. See Hbabt, Inflammation of. CABIES (caries, rottenness). — ^A destructive inflammatory disease of bone, analogoHB.to ulceration of soft tissues. See Bonb, Skiil. and Spinal Column, Diseases of. CABIiSB AD, in Bohemia. Thermal alkaline sulphated waters. See Minehal Watbes. CABMIBTATIVES (carmino, 1 card, or cleanse). _ Definition.— Substances that aid the expul- sion of flatus from the stomach and intestines, and relieve griping. CAEMINATIVES. E»UMBiiATioir.-'-Tli9 principal carminative remedies are — the Essential Aromatic Oils ; Chlo- roform : Charcoal ; Ethers ; and Camphors ; and substances containing them. Uses. — The uses of carminatives are suffi- ciently indicated in the preceding definition. They are extensively administered in cases of flatulent dyspepsia, especially 'when it is asso- ciated either 'with disease or disorder of the heart or with a nervous or hysteriejl state of the system. A combination of several different caiminatives is usually more successful than the exhibition of a single drug. With antacids they are useful in correcting acidity ; and they are frequently prescribed ■with purgatives to prevent pain. CABNIFICATIOir (faro, flesh, and fio, I become). — A condition of the lung in which its tissue resembles flesh. The term was formerly applied to the transformation of any tissue into a flesh-like substance. See Luhg, Collapse of. OAEPHOI.EGtL^^^^„_ chaff, and A^o,, OABPHOLOOyJ I collect). The move- ments of the hands and fingers observed in delirious patients, as if they were searching for or gathering imaginary objects. A familiar illustration of the aet is ' picking of the bed- clothes.' CABTIIiAQ-Si, Diseases of. — For 9, due appreciation of the abnormal conditions to which cartilage is subject, a brief description of this tissue in its healthy state is necessary. The temporary cartilage Which forms the early skeleton, gradually undergoes conversion into bone, leaving at the joint surfaces a thin layer, the articular cartilage, which never be- comes ossified, Certain other portions of the skeleton also retain their cartilaginous condition throughout life ; these are known as the perma- nent cartilages, and as examples the cartilages of' the ribs, ears, and nose may be given. The extremities of the long bones, or epiphyses, re- main separate from the shaft for a varying period after birth, and so long as the bone continues to grow, they are attached to it by a thin but impor- tant layer of cartilage, called the epiphysial car- tilage. There are yet the Jibrd-caHilages, in which the fibrous and cartilaginous elements are found in varying proportions, acebrding as the tenacity of the one or the elasticity of the' other mateiial is required. Cartilage is altogether destitute of nerves, and therefore of sensibility; and it is equally devoid of blood-vessels, being nourished by im- bibition from the vessels of the neighbouring parts. All cartilages, except the articular and the fibro-cartilages, are covered by a fibrous membrane, the perichondrium, which is similar to, and subserves the same purpose as the peri- osteum. "When cartilage has been destroyed it maybe replaced by fibrous tissue, or by bone, but it is never reproduced. Under the microscope a section of cartilage presents a transparent, structureless matrix, studded 'with nucleated cells; these cells are flattened and arranged parallel with the free sur- face of the cartilage, whilst more deeply they are elongated and grouped vertically. The nu- CAETILAGE, DISEASES OF. 211 trient materials are absorbed from the neigh- bouring blood-vessels, and transmitted throughout the cartilage by means of these cells. In those cartilages where tenacity or flexibility are needed, this hyaline substance is denser and, more dis- tinctly fibrillated than in the others. Summary of Dishasbs.— Cartilage being non- vascular, its inflammation is of a modified type, but it may undergo degenerative changes as a result of impaired nutrition. In uncomplicated disease of cartilage there is no inflammatory exu- dation, and when lymph or pus is found in a joint, it is obvious that other structures have become inflamed. 1. The ensiform and costal cartilages, with those of the trachea and larynx, show a great tendency to ossification, as the result of morbid change or senile decay ; they are also liable to necrosis. The articular cartilages never ossify, but large portions of them may perish and be detached,' in consequence of some interference 'with their supply of nutriment. 2. The cartilages of the epiglottis, ears, nose, eyelids, and eustachian tube have little disposition to ossify, but they are liable to ulceration, es- pecially of the syphilitic variety ; in these cases the diseased action commences in the skin or mucous membrane, and spreads to the cartilage by contiguity. 3. The cartilage, of the external ear is often the seat of chalk-stones in gouty persoUs, and similar deposits may also be found in the articu- lar cartilages. 4. The epiphysial cartilage may take on an ulcerative acfion, which leads to separation of the shaft from the epiphysis, a condition which, whether the result of disease or accident, is of great moment, inasmuch as the destruction of this layer of cartilage checks farther growth at the end of the bone. 5. Cartilage is not primarily attacked by can- cer, but it may become involved by the spread of a malignant tumour. The epitheUdl form of cancer not infrequently extends from the mu- cous or cutaneous surface, in which it originated, to the subjacent cartilage. 6. The articular cartilages are liable to cer- tain structural changes as the result of disturbed nutrition; and the fibro-caxtilages are also subject to the same abnormal conditions. Ulceration, absorption, degeneration of car- tilage are terms used to denote a series of destructive changes which take place in the substance of articular cartilage, and lead to its partial or complete removal. These changes may originate in the cartilage itself, or they may be secondary to disease of the bone or synovial membrane : however this may be, the morbid action is the same, and consists in increased cell- development, with disintegration of the hyaline substance. According to the observations of Goodsir and Eedfern.the cartilage- cells become enlarged, filled ■with nucleated corpuscles, and arranged irregu- larly; the distended cells then burst, and set free their contents upon the surface of or amongst the alteredhyaline substance. Whilst the cell-changes are taking _place,_ the matrix softens: in, acute cases it rapidly disintegrates and is discharged ; but when the disease is more chronic, it splits up 212 CABTILAGE, DISEASES OF. into fibres, •vrhicli remain attached ty one end to the cartilage, and by the other project loosely into the interior of the joint, giving a TJUous appearance to the affected spot. The remains of the matrix, and the granular contents of thei cells together form a fibro-nneleated membrane, 'which ultimately is conyerted into fibrous tissue, and constitutes the sole medium of repair -when a cure is effected. When this membrane is recent it has an indistinct granular appearance, from the presence of nuclei amount the fibres, and accord- ingtoEainey these nuclei are often converted into fat-globules ; •when the membrane is of older date it is distinctly fibrous ; and no doubt the several appearances which the membrane pre- sents under different circumstances has led to the several terms fihroua, fatty, and granular degeneration being applied to this disease, in the belief that they were really distinct pathological conditions. Ulceration generally commences upon the free surface of the cartilage, but it may begin at any part. It is usually superficial, but sometimes extends completely through the substance of the cartilage, exposing the bone : commonly limited in extent, it occasionally spreads over the whole surface; it is ordinarily confined to a single joint, but more than one may be affected. As a rule the disease progresses slowly, but it may run its course more rapidly. See Joints, Dis- eases of. 7. Hypertrophy of the articular cartilages has been described, but, as in these cases the car- tilage was found swollen and soft, it is probable that they were examples of commencing disease, rather than of actual increase of texture. 8. Atrophy has been observed as the result of pressure, and of the natural wasting •which occurs in advanced life ; it is also said to be occasion- ally produced in younger subjects by disease. Geo. G. Gascoybn. CASEOUS DEGEWERATIOIT.— A form of degeneration in which the products have the appearance of cheese. Bee Deqeneeations. OASTS. {Kast — Swedish and Danish — a throw.) DEFiNiTioir. — A term applied to moulds of gland-tubules and hollow ■viscera, thrown off in certain states of disease. Classification. — The varieties of casts met with may be represented according to the follow- ing arrangement : — A. — Casts of Gland-Tubules. s I Blood-Casts. Pus-Casts. I. Of the tTriniferous J Hyaline Casts. Tubules. 1 Granular Casts. I Epithelial Casts. I Fatty Casts. II. Of the Seminal Tubides. III. Of the Gastric Tubules. rV. Of the Cutaneous Glands. B.— Casts of Hollow Viscera and Passages. I. Of the Alimentary Canal. II. Of the TJrinary Bladder. lU. Of the Eemale Genital Passages. IV. Of the Respiratory Passages. CASTS. A.^Casts of Gland-Tdbules. I. Of the Uriniferoiia Tubules.— Dr. F, Simon of Berlin is usually credited with harag been the first to describe these bodies in his work on Medical CAemisiry, published in 1842; bnt it appears that before then they had been noticed and described by Vogla in 1837 and 1838, by Eayer in 1838, and by Nasse of Marburgin 1842. These observers, however, do not seem to Imve entered on the question of the origin, structure, or significance of these bodies, and for years they were looked upon rather as curiosities, and by some writers, notably Glup, were wholly disre- garded. Heller, in 1845, appears to have been the first to refer their origin to the coagulable matter of the blood, but it was some time after that date before their value in the diagnosis and prognosis of renal diseases came to be appre- ciated. This result has been mainly effected in this country by the labours of Basham, Beale, Johnson, W. Eoberts, Dickinson, and Grainger Stewart. Casts may be formed in any part of the kidney. They have been found in the convoluted tubules even up to the Malpighian capsules, and also in the straight tubules. - Not infre- quently small casts formed towards the termina- tions of the tubules come to be enclosed in their passage onwards 'within casts of the larger ones. Chaeactebs. — The urinary casts are mostly cylindrical in shape, frequently somewhat coiled and bent, and occasionally forked. Their length, depending very much on accidental circumstances, varies considerably. In sections of the kidney they may be traced occasionally for some distance in tiie tubules, becoming broken up into smaller pieces after leaving the kidney. In diameter the casts range between I'lOOOth and l'500th of an inch — the former being kno'wn as ' small,' the latter as ' large ' casts. The greater number are of a 'medium' size of l'700th of anineh. The diameter of the casts is in part determined h; the calibre of the tubule in which they are first formed, and in part by any subsequent additions they may receive in their passage outwards. Dr. Beale has suggested that after their formation the casts may probably shrink. In tubules that have become abnormally dilated or contracted, casts beyond the limits above mentioned may he found. The appearance of renal casts varies consider- ably, not only in different kidney-diseases, bnt also in various stages of the same affection. In all cases the cast consists of a solid cylinder of ii transparent or a very faintly granular substance, which in certain cases is fibnllated. What the nature of this base-substance is is still uncertain, and it appears probable that its composition is not constant in the different varieties of casts. It was formerly accepted that these bodies were produced by a coagulation of fibrin due to aa escape of blood-plasma into the tubules, and hence they were known as 'exudation-cylinders'— a term still often employed. It is easy to unde^ stand the formation of casts in this manner, and it is certain that such blood-oasis do occuii whether as shreds of fibrin with abundance of blood-corpuscles in its meshes, or as casts oos- CASTS, Bisting of little more than pure fibrin with its characteristic fibiillated appearance. In a similar munnei pus-casts, so called, may be produced. Flo. 5.— Blood Cafts. In those forms of renal disease, however, in which casts are found in the urine, when no hiemorrhage into the kidney tubes exists, one of the commonest appearances of these bodies is that of a transparent and faintly granular, tole- rably uniform cylinder, frequently somewhat rounded at the extremities, and often overlooked Fig. 6.— Hyaline Casts. unless searched for with care. In them no sign of fibrillation is to be discerned, and they do not correspond in their chemical behaviour to fibrin. These are the hyaline,- transparent, or viaxy casts, which may be large, small, or medium in diameter. What the substance is of which they are composed is uncertain. It is distinctly not fibrin, nor is it inspissated albumin, as has been suggested. In many cases a consider- able proportion of mucin has been obtained from them. Though frequently called ' waxy,' and often occurring in the urine from a waxy and amyloid kidney, it is extremely doubtful if they ever consist of the amyloid matter which is produced in the lardaceous degeneration of that organ. According to the writer's view this cast is the result of a colloid degeneration of the renal epithelial cells,, comparable to what is met with in other protoplasmic tissues. In consequence of this change in the cells they lose their normal appearance, and form into homogeneous, trans- parent masses, occupying the now denuded renal tubules, from which they are subsequently washed out by the urine secreted behind them. Other observers have regarded them as being formed of a substance secreted by the renal epithelial cells, rather than an actual conver- sion of the cells themselves. And Dr. Beale has ' thought it not improbable that these casts of the uriniferous tubes may really be composed of the material which in health ioTfoa the sub- stance of epithelial cells. In disease this sub- stance, perhaps somewhat altered or not perfectly formed, collects in the tubes and becomes inspis- sated.' Whaluver may be the true explanation of their formation, they present themselves as cemi-solid and somewhat viscid cylinders, readily 21S entangling ac^jaoent matter. Due totliis property is much of the variety they offer ; ijius, should the epithelium of the tubules be loosened, from Fia. 7.— Epithelial Casts. any cause, the cells will cohere to the cast which has been formed in the lumen of the tube, and an epithelial cast will be voided. Should the cells have undergone fatty degeneration the cast will be pervaded with oil-globules of all sizes, more or less escaped from epithelial cells, accord- FiG. 8.— Fatty Casts. ing to the extent of the degeneration ; this constitutes a fatty cast. Very frequently the casts are finely or coarsely granular, this appearance being produced by the involvement in Fio. 9.— Granular Oasts. the base-substance of the cast of granular mat- ter derived from broken-down epitielial cells or blood-oorpuscles, molecular fatty matter, or very frequently amorphous urinary salts. In a simi- lar way casts may be found containing crystals Fia. 10.— blasts enclosing oiystals ; and a smaller cast ; also of seminal tubule with spermatozoa. of oxalates, triple phosphates, &c. Very slight proof exists of any of the numerous theories that have been offered to explain their formation. It is very commonly the case that more than one variety of cast occurs in the . same urine, epithelial and hyaline, or granular and fatty, often co-existing. Corresponding to the casts in the urine, free epithelial cells, blood corpuscles, fat globules, and salts, amorphous or ciystallino, aro 2U always found. The epithelial cells, whether free or on the cast, are rarely quite normal in appear- ance. The pathological changes which have led to their desquamation haye at the same time altered them more or less. Not infrequently the cells of an epithelial cast present all the micro- scopic characters of leucocytes, having been pro- duced by an abnormal proliferation of the renal epithelium. Method of examination. — Samples of urine (three or four ounces) suspected to contain casts should be allowed to stand at least three hours in perfectly clean conical glasses, and a few drops should bs removed from the bottom with a pipette, and covered in the usual way on a glass slide. Por aU practical purposes a ^-in. objective, giving with the eye-piece a magnify- ing power of about 350 diameters, is sufficient. The hyaline casts are often so transparent as to escape any but the most careful observation, and then a little magenta or carmine staining fluid, introduced beneath the cover-glass, much facilitates their detection ; cutting off some of the light used has a similar effect. As a rule there is no mistaking a renal tube-cast, but occasion- ally a transparent or granular streak may be noticed, the nature of which cannot be positively stated ; shreds of mucus, especially when mixed up with granular matter, are the commonest ob- jects which simulate casts ; their disappearance on the application of a little heat to the slide de- termines their character. Clinical significance. — Valuable — almost in- . dispensable — as is the evidence afforded by the detection of these bodies in the urine, their re- cognition and comprehension is nevertheless but one of the means to be employed in the study of renal diseases. Of themselves they afford practical information, rarely, if ever, conclusive when taken alone. Without doubt certain renal diseases may exist, and may continue throughout their course either to recovery or death, without the occurrence of casts in the urine. But for all practical pur- poses it may be accepted that when casts do occur, they indicate the existence of a disease of the kidneys which is possibly incurable, certainly serious. Besides the value of casts in deter- mining the existence of kidney-disease, they are further most important aids in helping to dis- tinguish what variety or stage of disease it may be, and also in making out the actual condition of the kidney, thus furnishing valuable data on which to form a prognosis, and to suggest a plan of treatment. Little is to be seen, however, from one exami- nation. This should be performed frequently, as in that way alone can the morbid progress in the kidney be recognised, From what has been said of the nature of casts, it should be expected — as is the case — that several varieties of these bodies occur at the same time in the urine. It is rare for any variety to exist singly, at least for any time. In such cases their significance is ascertained by careful study of coincident circumstances, and especially by a frequent comparison, in order to determine which variety is in excess. The fact that casts are very abundant in any sample of urine is not in itself of necessity a CASTS. serious sign. Thus in 'granular kidney' — oneof the most serious of all renal affections, — the casts may be, and usually are very few, and require careful looking for ; whilst in the convalescence from acute nephritis they may be extremely numerous. In chronic nephritis, however, the number becomes an important element in the consideration. Blood-casts are diagnostic of haemorrhage into the tubules, whether that be due to intense arterial hyperaemia or to venous congestion- such as exists in acute Bright's disease from whatever cause — ^resulting in escape of blood from the vessels. Pus-casts may indicate the bursting of a renal abscess into the tubes, and coagulation of tlie escaped pus. Very often, however, the leucocytes which take part in the formation of a pus- oast have another origin, viz. from the renal epithelial cells, being the result of their proh- feratiou in the inflamed state. Si/aline casts. — The large forms of this variety chiefly occur in chronic nephritis, and are there- fore usually a grave sign. Produced in tubules which have been denuded of their epithelium, or in others that have become dilated from con- tractions in the intertubular substance, they indicate an advanced condition of disease. Ex- ceptions to this do occur, and large hyaline casts may be found in acute and curable cases. Small hyaline casts are formed in both acute and chronic forms of renal disease. They there- fore become valuable as means of diagnosis only in conjunction with other signs, such as the his- tory, of the case, the character of the other urinary sediments, &e. They are frequently seen in acute nephritis, particularly in the later stages of the disease, and are then formed in tubes which have not been stripped of theit epithelial lining. In simple congestion of the kidney they may be formed, from a coagulation of the fibrin of the effused plasma. When associated with the large variety they usually indicate a chronic and advanced stage, being then found in tubules that have become contracted. These two varie- ties of hyaline casts are common in the albumi- noid kidney, and similar casts have been met with in the tubules in cases of diphtheria. Granular casts. — The significance of these is very variable. As has been said, the granular easts differ much in nature, and no positive diagnosis can be made upon them alone. They may occur in conjunction with blood-casts where the cor- puscles have broken down, and they wiU then generally indicate a commencing recovery from an acute stage. A similar interpretation may sometimes be put on casts whose granulation is due to fat molecules resulting from the degene- ration of inflammatory products. Large, dark, and coarsely granular casts are more particularly noticed in ' granular kidney,' where indeed they may be the only casts found. In such circum- stances they become a very serious sign. In the later stages of chronic nephritis the epithelial cells disintegrate and produce granular casts. EpiUheliiil casts. — These are more especially met with in the earlier stages of nephritis, and their significance much: depends on the character of the epithelium cells. They may be very abun- dant at first; later on, when the hyaline variety CASTS. 21B appears in the virine, becoming less numerous. Tlie epithelium cells may differ but little from the normal renal epithelium, or they may be fatty and more like leucocytes in appearance. Fatty caste.— Probably no casts are so general in their occurrence as these. Their presence may bo of the gravest import, or they may be- token commencing recovery, and more than any, therefore, must they be considered in connexion with other circumstances. The casta that are found in the later stages of acute nephritis dur- ing convalescence are in part fatty. The inflam- matory products undergoing this degeneration are those thrown off. Hyaline casts, both large and small, frequently present a few oil-globules on their surface. And in certain forms of chronic nephritis the casts may appear as if made up of oil-globules only. In such ease an adva,noed stage of fatty degeneration of the gland is distinctly indicated, and the persistence of fatty casts is generally taken to signify the same; though such casts have been known to continue in num- bers for some weeks, and to be followed by recovery. Cmts in non-albumiamcs urine. — The exist- ence of renal casts in such urine has been noticed for some time past. ' If the casts were formed from any of the elements of the blood, their appearance could not be explained ; but if, as has been said, these bodies owe their forma- tion to the degeneration of, or of a secretion from, epithelial cells, their occurrence under such cir- cumstances is intelligible. The conclusion that the urine is non-albuminous must not be too readily made ; there may be so small an amount as to escape notice with the ordiaary rough method of testing, and there may be only a tem- porary disappearance of the albumin. , The casts that are formed in non-albuminous urine are of the hyaline variety. Those that are frequently found in the urine of persons suffering from icterus from what- ever cause, and which are stated by Nothnagel to be, in direct proportion to the intensity of the jaundice, are said not to be associated with albiimin. The pathology of these casts is not as yet understood. II. Of tte Seminal Tubules.— Dr. Beale has pointed out the occasional existence in urine of casta containing spermatozoa (see Pig. 10). The basor-substance of their bodies is a viscid tenacious mucus, and they are usually much larger than the casts derived from the uriniferous tubules. They have not been found associated with inflammatory conditions of the testicle, and do not correspond pathologically to the renal casts above described. III. Of the Gastric Tubules. — In inflam- mation of the gastrip mucous membrane, espe- cially in scarlet fever, a desquamation of the epi- thelial coat involving the glands has been noticed. The casts of the follicles have been , found in the vomit, and more abundantly in the contents of the !itoma.chpost mortem. Their length is variable, and in width they range from jjjth to j^th of an inch. The base-substance is de- scribed as fibrinous, and is covered more or less completely by altered epithelial cells and granular dSbris. IV. Of the Cutaneous Ctlaads. — In the va- rious skin-affections which are associated with desquamation of the cuticle, casts of varying length, coming from the sweat- and sebaceous glands, aro thrown off as part of the general shedding of the epidermis. Such bodies are hollow. tubes, and bear no resemblance to the inflammatory casts in nephritis. B.- -Casts of Hollow Visceea and Passages. Prom time to time, more or less perfect casts of these organs are met with. The conditions which determine their occurrence are but im- perfectly understood; they /are in some cases associated with inflammation of the surfaces from which they are thrown off, but in other cases appear to be independent of any such morbid changes. I. Of the Alimentary Canal.— Inflammation of any part of the canal, from mouth to rectum, has been known to give rise to the detachment of flakes of the superficial epithelium embodied in a very viscid, tenacious mucus. It is in scarlet fever that this condition has been usually seen, where the degeneration of the mucous membrane corresponds to the skin-shedding. Occasionally complete hollow moulds of portions of the intestine are found, and large pieces have been recognised as coming from the stomach (Beale). Similar results may follow croupous and diph- theritic inflammation. II. Of the Urinary Bladder. — A complete exfoliation of the mucous membrane of the blad- der has been occasionally observed in puerperal women. It does not appear to be always the result of inflammation, and though the detach- ment may be complete, perfect recovery may follow. In structure such bodies consist of epithelial cells in varying stages of degeneration, felted together by mucus and fine granular material. The surface is frequently thickly coated with urinary salts. The conditions giving rise to their formation are quite unknown, though retention of urine is associated with their occur- rence. III. Of the Female Genital Passages. — Casts of the uterus and vagina have been fre- quently noticed. Occasionally they are thrown off periodically, and may then be accompanied with much pain andhsemorrhage (membranous dysme- norrhcea). Partial casts of the passages have also been found associated with diphtheria. These false membranes may form complete casts of the uterus, leaving only the orifices of the in- ternal OS and Pallopian tubes, and appear as shaggy bags, consisting of the epithelial layer of the organ. Sometimes these bodies may be the decidua in an early stage, but they have also been met with in virgins. IV. Of the Besplratory Passages. — Casts of some portion of the air-tubes are of frequent occurrence, associated with a special form of in- flammation, known as croupous or diphtheritic. In such cases the epithelial covering of the mucous membrane comes to be replaced by a la,yer of material which is derived from the metamor- phosed epithelial cells, with a variable amount of coagulated fibrin formed from the effused blood- plasma. Such false membrane appears Under the microscope to be made up of interlacing 216 CASTS. fibres of a clear homogeneous-looking substance, felted together in all directions, and containing in the mashea leucocytes, altered epithelial cells, blood-corpuscles, and a small quantity of serum. The exact method of formation of such a mem- brane is still a matter of dispute — ^how far it de- pends for its occurrence on blood-fibrin, and how far on ' croupous metamorphosis ' of the ori- ginal epithelial cells, such as was described in speaking of the formation of hyaline renal casts. The fibrous material of the membrane, however formed, strongly resists the action of ordinary reagents. It is easy to understand that the extent to which the materials constituting this membrane infiltrate the deeper layers of the mucous mem- brane, must vary considerably; yet in the extent of infiltration and consequent adherence, very much depends the distinction, such as it is, be- tween croupous and diphtheritic exudation. In the larynx and trachea, the new material forms mora or less complete layers, covering the vocal cords, dipping into the ventricles, and even blocking up the laryngeal cavity completely. By the effusion of serum beneath iJia membrane, it is loosened and may be expectorated in pieces varying in size from mere shreds up to complete When this inflammatory product originates in the bronchial tubes, it forms the so-called bron- chial polypi, so characteristic of Plastic Bron- chitis. It is rare for more than very limited areas of the air-passages to be so affected, but within these areas perfect casts of the entire extent from trachea to alveoli may be ob- tained. Expectorated as irregular, roUed-nj*, and twisted masses, they are capable of being shaken out in water into ramifying whitish,, or pinky white, moulds of the tubes. They are either hollow and membranous or solid, and in the latter case frequently present indications of being made up of concentric layers. Similar casts of the smallest tubes are found in the ex- pectoration of acute croupous pneumonia. It would seem then that the material formed on the surface of the mucous membrane of the air-pas- sages throughout their whole extent, and which may form more or less perfect casts of their passages, is identical in structure, and probably in method of formation, wherever be its situation, whether limited to the larynx and trachea (croup and diphtheria), or only in the terminal air- tubes (acute croupous pneumonia), or throughout the entire length (plastic bronchitis). "W. H. Aii-CHiN. CATALEPSY (KaT(i\in)'ir, a seizure). — Definition. — A disease of the nervous system, characterised by attacks of powerlessness, com- monly with loss of consciousness, accompanied by a peculiar form of muscular rigidity, in which the limbs remain for a time in the position in which they are placed. JETKyLOar. — Catalepsy may occur at all ages between six and sixty years, and in both sexes, but it is incomparably more frequent in the female sex and in early adult life, at or soon after puberty. It is, in the majority of cases, associated with distinct evidence of hysteria : and in other cases, in which no hysterical symptoms CATALEPSY. have preceded it, the affection may be traced to such exciting causes as give rise to the hysterical paroxysm. Nervous exhaustion is the common predisponent ; and emotional disturbance, espe- cially religious excitement, or sudden alarm, and blows on the head and back, are frequent immediate causes. It occasionally occurs in the course of mental affections, especially melan- cholia, and as an early symptom of epilepsy, In an imperfect form it has appeared to be due, in some cases, to paludal poisoning or to other toxsemic states, as chloroform-narcosis. In a few cases meningitis, and other organic cerebral or spinal diseases, have caused a cataleptoid cdn> dition : but these cases are too rare and divemp to allow of any inference from them. Symptoms. — In some cases headache, giddi- ness, or hiccough, has preceded the attack. The onset of the special symptoms is usually suddes, coiomonly with loss of consciousness. The whole or part of the muscular system passes into a state of rigidity. The limbs remain in the posi- tion they occupied at the onset, as if petrified. The muscular rigidity is- at first considerable, and movement is resisted ; but aftera short time the limbs can be moved, and then remain in the position in which they may be placed. The resistance to passive movement is peculiar : it is as if the limbs were made of wax, and hence the condition has been teimei Jlexibilitas cerea. The rigidity commonly yields slowly to gravitation. The countenance is usually expressionless. The respiratory moveonents and heart's action are weakened. Substances placed in the back of the mouth are swallowed, but slowly. The state of sensibility varies ; in profound conditions of catalepsy it is lost to touch, pain, and electricity, and no reflex movements can be induced even by touching the conjunctiva. In other cases partial sensibility remains, and reflex phenomena may be excited. In rare instances paroxysmal hyperaesthesia is present. Consciousness is fre- quently lost, but may remain, rarely intact, more often in an obscured condition. The tem- perature is commonly lowered. The attack may last a few minutes or several hours. Eecovery is gradual or sudden ; it is common for the patient at first to be unable to speak. Some- times a strange periodicity may be observed in the occurrence of the paroxysms. In the intervals between the attacks, headache, giddiness, or hysterical manifestations may be present, or the patient may feel and seem perfectly well. Pathology. — Concerning the nature of the disease there has been much speculation, but little definite knowledge. It may probably be placed between epilepsy and hysteria in the scale of maladies. There is distinct interference with the intellectual processes, and interruption of the connection between the vrill and the motor cen- tres. The rigidity has been thought by Rosen- thal to be reflex, but the abeyance of other reflex symptoms makes it more probable that, as Holm suggests, it is of central origin. Diagnosis. — Many cases of simple trance have been included under Catalepsy, but it is better to restrict the name to the condition in which the_ peculiar rigidity exists. Hysteria with tonic spasm has also been erroneously tfermed catalepsy. The condition is sometimes simulated ; CATALEPSY. m trno catalepsy the rigid limb slo-wly yields to the influence of gravitation, and more rapidly if a -weight he attached to it ; in the feigned form the limh and -weight are held firm. Prognosis. — ^The prognosis is favourable in simple catalepsy, in proportion to the freedom of the intervals from affections of sensibility or motion. In pronounced hysteria and psychical affections the condition is often obstinate, and, by interfering -with the due nourishment of the system, may cause grave inanition. Trbatmbnt.: — ^During the attack itself little can be done save an attempt, -which may be re- peated at intervals, to rouse consci-ousness by external stimulation. The ordinary applications, ammonia to the nostrils, cold douches, &c., often fail. A pinch of snuff -will, however, often suc- ceed. Another effectual stimulant is Faradisa- tion. It may be applied to a limb or to the cervical spine. The current should be gentle at first, and gradually increased. Emetics are also usefiil in cutting short an attack. Injections of tartar emetic into the veins have been used -with success by Calvi, but can hardly be recom- mended. Subcutaneous injection of apOmorphia, j^jth to ^th of a grain, the writer has found an efJcient remedy for similar paroxysmal condi- tions; with the onset of nausea, about five minutes after the injection, consciousness is re- gained, and all spasm ceases. In the intervals between the attacks the treatment is that of hysteria. Iron, antispasmodics, especially vale- rian, alvetic aperients, and cold baths, are the most effectual measures. Firm moral treatment is also indispensable. Bemoval from home influences is often necessary to effect a cure. W. E. Gb-WEBs. CATAMBKIA, Disorders of. See Men- STBCATioN, Disorders of. CATAPLASM (naTcb, down, and ir\<{ffiri>j, I mould or smear). — A synonym for a poultice. See PoTiLTiCE. CATARACT (Karapdierri!, a -waterfall). — DBFiNirtoN. — Cataract is an opacity of the lens — the -want of transparency beirig suiBcient to prevent, at least in that part of the lens which is opaque and to the extent of the opacity, the discrimination, with the ophthalmoscopic mirror, of the details of the fundus of the eye. .SJtiologt and Pathology. — Cataract is pro- duced invarious ways. Any change in the nor- mal relationship of the lens-fibres may cause such a degree of opacity of the lens as is understood by the term cataractous. This is usually a senile change, and it is then a sclerosis of the lens. The question of the normal nutrition of the lens is yet unanswered. If there be a solution of continuity of tho capsule of the lens, so that the aqueous humour has access to the lens proper, unless it be in cases of minute punctures and small, Clean-cut -wounds, which soon heal and scar, the whole lens becomes swollen by endos- mosis, grey, and cataractous. A symmetrical change in the lenses, somewhat similar in appearance, is observed in some cases of diabetes, and is occasionally seen in albuminuria. The lens may be found to be ill-developed and cataractous at birth; while others, apparently as a consequence of ill-development, but not CATAEACT. 217 during the whole period of growth of tho lens, are partly cataractous and partly transparent, and show opaque concentric lamellse. Besides this instance, showing the anatomical configu- ration of the lens, cataracts not unfrequently demonstrate its normal trifid division as trans- parent lines; and the strise of striated cataracts are always in directions radiating to or from tho centre of the lens, in the course of the fibres. Besides these scleroses, endosmoses, and im- perfections of the lens proper, there are many opacities appertaining to this part of the refrac- tive apparatus, which were formerly, and are still commonly called cataract. Amoilg these there are the capsular cataracts, which do. not imply any real opacity of the capsule of the lens, but only an opacity of that part of the lens which is next to the capsule — the rest remaining transparent — or the deposit of some opaque mat- ter upon the lens-capsule externally. Fyra- midal cataract is formed by the deposit on the anterior surface of the front of the lens-capsule, at or near its centre, of a patch of lymph, when an -ulcer has formed in the cornea, and perfora- tion has occurred, by which the aqueous humour is evaxiuated, the anterior chamber obliterated, and the lens approximated to the cornea, if it is not brought into actual contact with it. When the aqueous humour is again retained, the mass of lymph is dra-wh out into the pyraiinidal form, and if, in any case of pyramidal cataract, there has been no perforating ulcer to evaciuite the aqueous humour, it must be remembered that these so-called cataracts only occur in early life, when the anterior chamber is very ' shallow. There is a large class of cataracts called secon- dary, where the condition is due to an earlier disease of the eye, and in which the latter is of course in the first place to be considered. Such cases are the glaucomatous, in which, when excessive intraocular pressure has existed some time, the lens, no doubt by interference with its due nutrition, becomes cataractous ; and iridec- tomy for glaucoma is chiefly indicated, whether or not the lens should require to be extracted subsequently. Other Secondary cataracts are those called postenor-polar, in which the opacity begins at the centre of the back of the lens and is preceded by some deep-seated disease of the fundus of the eye, which is of greater and cer- tainly of prior importance. Symptoms. — A patient, having uncomplicated cataract, complains of his vision, if he complains at all, for a small deflnite opacity is easily dis- regarded, even if it be in or near the centre of the lens or of the axis of vision. If it occupies a considerable portion of the pupillary area, it can of course be no longer considered small, or be disregarded by the patient. If the cataract- ous opacity begins in the circumferential parts of the lens, and only there, it may,, on the contrary, make very considerable progress before it is found out by the patient. In the majority of the various cases of cataract, the patient sees better with his pupils dilated — he prefers to git with his back to the light, he holds his hand over his eyes, or he holds his head down and fro-wna in order to see better-r-he is cheerful, and is al- -ways trying to see. In such cases as these quacks have made profit of the benefit the patient has 218 derived from each visit, when a drop of bella- donna or atropine solution has been used for the • cure ' of the malady. The only complication or ill result of the_ ex- istence of non-traumatio cataract as such,. is in the congenital forms, in which for want of use the retina suffers and nystagmus follow8._ It is thersfora imperative that cataract in infancy should be operated on at an early age. Diagnosis. — The diagnosis of cataract is, in most cases, easy enough. The position and shape of the crystalline lens being known, an opaque body is seen to exist in its place, or in a part of it. The cataractous opacity varies from milky to chalky white ; striae in it often appear glistening, like newly-dissected tendon ; some cataracts are amber-coloured. A drop of liquor atropiee sul- phatis should be used to dilate the pupil ; and, this being effected, the opacity behind it cannot be one of the results of a past iritis, which would not leave the pupil free to dilate fully and cir- cularly. The ophthalmoscope should then be used, not only for the diagnosis of a cataract, but also for ascertaining the degree of opacity, and, if not too late, the state of the fundus ; and for determining thus the probable future need and success of an operation for its removal. If, not- withstanding an evident opacity in the situation of the lens, otherwise seen, all the details of the fundus viewed with the ophthalmoscope are unobstruetedly discernible, it is not a case of true cataract. Senile lenses have, as a rule, an evident diffused opacity which does not imply any beg^ning of cataract formation. There are generally striae in the cataractous lens, which converge to the centre from the circumference, or diverge &om the centre to the circumference, and if the fundus can be illuminated with the ophthal- moscopic mirror, the opaque parts of the lens appear dark, the reflected light coming from behind them ; but, on the other hand, if the ophthalmoscopic convex lens be used to concen- trate the lamp-light obliquely on the cataract, the opaque parts appear light, as they reflect the light, and are backed by the fundus which is not thus lit up. Strise on the posterior surface of the lens are seen to be concave ; and, in senile cases, being viewed through a lens having the natural yellow tint of senile lenses, they also appear yellowish. Some cataracts begin as a haziness, chiefly in the centre, the so-called TiKcfeas, which is' always increasing; and, seen by oblique illumination, there is in these cases, on the side of the light, a shadow of the iris cast on the light-reflecting opacity, and the lens-opacity seems to be most on the side furthest from the light, whichever that may be. Pboonosis. — The prognosis of cataract, in a medical sense, is bad. It is very doubtful if it ever can be at all arrested in its progress, not to say cured or even lessened. In all probability the cataractous opacity is scarcely ever di- minished—on the other hand it does not always progress. _ Very many old persons have cataract- ous strise in the marginal part of their lenses, which are of no inconvenience to them, and are only by chance discovered by the surgeon. If the striae should invade the pupillary area, vision, in one eye at least, will be very likely still sufficient for the requu-ements of the patient, and the in- CATARACT. terference of the surgeon will never be called for. As to the prospects of success in operating— un^ complicated; cataract, of course, never leads to ab- solute blindness — the patient sees and evidently observes the light and light-reflecting objects ; the field of vision is perfect ; the pupil is active ; the general health is good ; the cataractous opacity is not of the posterior-polar variety, and there are no other complications ; all parts of the lens are more or less opaque. Immature cataracts must not be extracted unless, neither eye is good for vision, and the progress to- wards maturity is exceedingly tedious, because the transparent parts of, the lens, unseen, are likely to be left behind in the operationj and then to set up inflammation. The dangers from cb' taract operations are less in childhood than in older persons. In early life any subsequent; in* flammation threatening the eye can be averted by timely interference with a certainty of suc- cess, and an operation should therefore be recom- mended, although the cataract only affects one eye. In old age if one eye be available for vision, an operation for mature cataract in the. other eye is not to be performed imlesa the patient himself desires it. TREATMENT.^-Cataracts have seldom, the writer believes, any practical bearing as regards medical treatment. In cases of diabetes and of temporary albuminuria, in which a cataractous condition occurred, the state of the lens has been found to improve with the general health of the patient. In a patient with diabetic cataracts appropriate treatment may remove the opacity of the lenses and restore vision ; and the writer has seen senile cataract advance rapidly when the patient has been in any way lowered in general health, and then again advance slowly as before when the health has been restored. Besides the palliative treatment by atropine drops constantly used (if vision be improved by their use), the capital surgical treatment is the only one available for cataract— the opaque lenses must be removed, and spectacles of differ- ent powers must be worn as substitutes foi the natural lenses and power of accommodation. Exception must be made in the case of some lameUar cataracts, with a wide transparent mar- gin, in which an iridectomy is sufficient for the restoration of vision. In infancy and youth the best proceeding is the needle-operation, by which, with a flne needle only, entered through the co^ nea, the anterior capsule of the lens, and the lens itself also to some extent, are broken up, and, by repetitions of the same operation, the whole is exposed to the action of the aqueous humour and thus gradually absorbed, the posterior lens-cap- sule being left as a barrier to the vitreous humour behind it. It is v^ry safe when atropine drops are constantly used, and the case is continually watched, so tliat, if too sudden or too great a swelling of lens-matter should at any time occur by the admission of the aqueous humour, and there be a threatening of iritis as a consequence of mechanical pressure on the iris, the swollen lens-matter may be at once evacuated by the introduction of a broad needle through the cornea, and then of a grooved curette or suction-syringe, by which the semifluid mass, or a sufficient quantity of it, may be got rid of. In old age. and CATARACT. Cenerally in adult life, the oataractous lens to be removed should undoubtedly be extracted as a whole and at one time.. The needle operations, which in young persons are not completed in any case in less than a few weeks or months, take a longer time to complete in proportion to the age of the patient ; in adults the process is much slower, and in old age it would be indefinitely prolonged; more important still, the eyes by age become less and less tolerant of what maybe calledaforeignbody.andmoreliabletoiritis.while the iritis is less easily subdued. Then again the central part or nudeua of the lens especially grows harder as the patient becomes older ; and if the patient be too old for the safe adoption of the minor operation, this so-called nucleus would become a much more likely source of irritation, particularly if it floated freely in the aqueous humour, than the swollen soft lens-matter of the juvenile lens when thus operated upon. The so- called hard cataracts of old age must, -without doubt, be extracted. A section with a knife is made, of somewhat less than half of the corneal circumference ; then, as is usually practised now- a-days, that part of the iris lying beneath the corneal section is excised, for the easier and more safe extrusion of the hard lens ; the anterior cap- sule of the lens is freely lacerated; and, by pres- sure in the ciliary region opposite to the open- ing made, the lens is gradually forced out of its capsule and out of the eye, including subse- quentiy all the softer circumferential cortical parts of the cataractous lens. The edges of the corneal wound being rightly in apposition, the eyelids are closed, and both eyes are firmly but lightly bandaged for some days, until at least the corneal wound is healed, so that the aqueous humour is again retained. The cataracts of adults, though they may not he old people, in most cases should also be extracted. But at this age cataracts are not common, except traumatic cata- racts, and these, and many other varieties, cannot be briefly described in a general way. J. F. Steeatfeild. OATAEBH {xarvi, down, and ^ta, I flow). Sy»on. : Coryza; Cteton-AMs (Cullen) ; Catarrhm Communis (Good) ; Bhmma ; Fr. Catarrhe, Coryma ; Ger. Katwrrh, Schmipfen, Dbfikitiok. — The term catarrh is applied generally to inflammations of the mucous mem- branes attended with increased secretion. Thus authors speak of catarrh of the stomach, intettines, bladder, ^c. In the present article the term is limited to the inflammatory afiections of the iipper part of the air-passages, resulting from cold, and attended by discharge from the nostrils, sore- ness of the throat, hoarseness, and cough. The term coryza is, however, more especially limited to the cases in which there is copious discharge from the nasal passages, while catarrh is applied to affections of the whole mucous membrane, in- cluding the fauces and larynx. Symptoms. — ^The attack generally commences, shortly after exposure to cold or more particu- larly to cold and damp, with a feeling of indisposition, sense of cold down the back or general ' chilliness, weight in the forehead, headache, especially frontal, and dryness of the naios and throat. These symptoms are succeeded OATAEBH. 219 by the discharge from the nostrils of a thin acrid fluid, watering of the eyes, pains in the face, soreness of the throat and hoarseness, with aching in all parts of the body, and disinclination to bodily and mental exertion. At first the affection is often confined to one nostril, and there is pain in the corresponding temple, eyebrow, eyeball, and side of the face, and lachrymation on that side, but it soon ap- pears in the other nostril, and involves both eyes and all parts of the face ; and there is great sense of weight and pain in the forehead and eye-brows. The discharge, also, loses the thin character and becomes mucous, and is often very profuse ; there is copious lachrymation, the throat becomes decidedly sore, the hoarseness is greater, and there is pain in speaking and sometimes almost entire loss of voice. There are also tran- sient pains In the chest, with a sense of tightness and some wheezing. The appetite fi'om the first is impaired, and there may be entire distaste for food, and sometimes sickness and vomiting ; not unfrequently there is some sense of weight in the i^ight hypochondrium, and sallowness of the com- plexion ; the bowels are usually confined, but there may be diarrhcea. The tongue is generally white, the pulse may be a little quickened, the skin may be dry, the temperature is raised, and the urine is scanty and somewhat high-coloured and deposits a little sediment. The pains in the head and face especially affect the forehead, the eyebrows, the root of the nose, the eye-balls, and the course of the dental and other nerves ; they generally increase towards night, and may be so severe as entirely to prevent sleep. Not unfrequently there is more or less deafness, and usually loss of smell and taste. Herpetic spots often appear about the mouth, and the nostrils may become ulcerated from the discharge ; the throat is more or less red and swollen, and often there is stifhess and pain of the neck, and tender- ness on pressure over the larynx. After these symptoms have continued for two or three days they generally gradually subside ; but the cough may continue troublesome, and the patient be able to take very little food, and may still feel weak for a week or more. In per- sons of delicate constitution also, the weakness is often very persistent ; and, if care be not taken, more serious inflammation of the bronchial mu- cous membrane or of the lungs may supervene, and may lapse into phthisis. Teeatmeot-. — In the slighter forms of com- mon cold, but little treatment is required except the use of the ordinary household remedies: the feet may be placed in hot water, some warm diluent beverage may be taken, and a light diet must be had recourse to for a day or two. In the more serious cases febrifuge medicines may be given, with an anodyne to relieve the cough, if troublesome, or to procure rest at ■ night, if the neuralgic pains be very severe. When the attack has continued for two or three days a more stimulating diet may be given, and during convalescence tonics and stimulants may be re- quired. Dr. Ferrier recommends in catarrh the local application to the nose of the following powder in the form of a snuff— Hydrochiorate of mor- phia 2 grains, subnitrate of bismuth 6 drachms. 220 CATAHEH. gum-aeacia in powder 2 drachms. Frow one- quarter to one-half of this may he taken in the course of twenty-four hours. It not unfrequently happens that in delicate persons a cold is very difficult to get rid of, and the B]ightest exposure is followed by an aggrava- tion or renewal of the symptoms. When this is the case the most effectual remedy is change of air, and the patient after leaving home often rapidly improves and soon gets well. Thomas B. Pea.cock. OATABEHAIi (Karefc, down, and ^eoi, I flow). — Pertaining to catarrh, both in its pathological and in its clinical signifieation-^c.^., catarrhal products, catarrhal pneumonia, catarrhal fever, catarrhal attack. CATHAKTICS (jcaedpa, I cleanse).— This word is sometimes used as a synonym for purgatives ; but in a more limited signification it means purgatives of moderate activity. See PUBQATIVES. CAITSS3 of Disease, See Disease, Causes o£ CATJSTIOS ((talai, I hum) Definition. — Substances or measures which destroy organic tissues with which they may be brought in con- tact. Endmehation. — The caustic substances in most common use are Potash, Soda, and Liitie ; Nitric, Hydrochloric, Sulphuric, and Glacial Acetic Acids ; Red Oxide, Acid Nitrate, and Per- chloride of Mercury; Carbolic Acid; Chromic Acid ; Chloride of Zinc ; Chloride of Antimony ; and Arsenic. The -ordinary caustic measures are the galvano-oautery ; the red-hot iron ; and moioB. See also Poisons. Uses. — Caustics are chiefly employed to destroy unhealthy, exuberant, or md.igQant growths ; to establish issues for the purpose of counter-irritation (see Countee-ikhitation) ; and to destroy poisons when introduced into the body by breach of the external surface. T. Laudee Becnton. CATTTEEETS, in the French. FTrenees. Sulphur Waters. See Mineeai Waters. OATEBITOTTS. — A peculiar quality of sounds heard on auscultation of the lungs, indica- tive of the presence of a cavity. See Physical Examination. CAVITY, Pulmonary. — As the result of certain morbid processes which terminate in the destruction of portions of the pulmonary tissues, abnormal spaces or excavations are frequently farmed in the lungs, which are designated cavi- ties or vomica. These are usually associated with, and are by far most important in that large class of cases which are grouped under the term Phthisis. They may, however, originate under other conditions, namely, as the result of abscess or gangrene of the lung; of the destruction of morbid growths or hydatid cysts ; of dilatation of the bronchi ; or of destruction of the pulmo- nary tissue from without, in connection with glandular diseas», empysema, and other lesions. The most recent observations on this subject are giyen in the article Vomica. Fulmonaiy cavities present wide variations in CELL. different cases aa regards their number, size, shape, condition of their walls, amount and nature of their contents, and other particulars. Usually they begin to form in the upper part of one lung, but subsequently they are produced in other parts, frequently both lungs becoming more or less involved, and any portion may be exca- vated is the first instance. A cavity frequently goes through certain stages, namely, those of formation and extension ; of arrest ; and of heal- ing or contraction, which may terminate in ulti- mate closure and obliteration of the vomica. Enlargement of cavities is effected either by progressive implication of their walls, termi- nating in their disorganisation and removal ; or by coalescence of adjacent spaces, the intervening lung-tissue becoming destroyed. During this pro- cess of destruction some of th« tissues often escape more or less, especially the vessels, which may not uncommonly be seen traversing the spaces or running along their walls, their channel being obliterated, . When an excavation is arrested is its progress, it becomes lined by a smooth mem- brane, and a more or less purulent fluid is se- creted within it. This cessation of active mischief may not take place until a whole lobe, or even the greater part of the lung, is involved, a huge cavity being formed, which presents no tendency to contract. In other instances the progress of destruction is stayed, the formation of purulent matter is checked and finally ceases, a fibroid tissue forms, and the space undergoes a process of contraction or cicatrization, which may end in a complete cure, but more commonly merely diminishes the size of the vomica more or less. At a post-mortem examination in cases of phtliisis it is common to find nnmerous cavities in the various conditions and stages indicated above. Occasionally a vomica gives way into the pleura, followed bypneumbthorax and its consequences. Clinically, the existence of cavities in the lungs can only be ascertained positively by physical examination of the chest, and as a rule not only their presence, but their conditions may by this means be determined with tolerable accuracy. The physical signs vary considerably in different cases, and are more conveniently described in other articles. See Phthisis; Physical Examuja- TioN, and Vomica. Feedeeiok T. Eobebts. OELIi {eella, a closet or store-room).— The term ' cell ' was for a long time applied, in anatomy, to various spaces in the body large enough to be recognised with the naked eye. In the Anatomie Gmtrale of Bichat, for instance, it was used exclnsivdy-for the ir- regular spaces in areolar tissue (still often called cellular tisstie). An entirely different sense of the word was introduced from botanical science. The microscope had shown that the structure of plants was largely made up of hollow bodies, called bladders, vesicles, or cells, in which various substances were enclosed ot stored up. Schwann was the first to show the similarity in structure of many animal tissues, which were likeviise made up of minute parts. These parts were assumed to be, as in plants, hollow ; and in both cases, cells were defined as composed of a cell-wall, cell-contents, and a smaller included mass called the nucleus. CELL. 221 This conception of a cell still holds its ground in the anatomy of plants. It did so in animal histology till about the year 1861, when Beale, Bmcke, and Max Schultze almost simultaneously showed that many so-called cells in animal tissues did not possess the typical structure of a cell, but were homogeneous masses of a sub- stance resembling the bodies of many lower animals, which substance Schultze distinguished fay the name of protoplasm. This was first shown to be true of certain special cells, such as the corpuscles of blood and lymph, but afterwards extended more widely, till now it is doubtful whether any minute elements in the higher animals, with the possible exception of the fat-cells when gorged with fat, and certain peculiar forms of cell on the mucous surfaces, come under the old definition of a cell. When the conception was altered, it would probably have been better to have introduced a new name. This, however, was not done, and hence the word cell as now used involves some incon- sistency. By ' ceU,' we now understand a mass of con- tractile, colloid, living matter called protoplasm, containing at some period or other a smaller structure called the miclem. It must remain uncertain whether the nucleus is or is not essen- tial to the cell, till we know more about the nature and function of the former; and these points, in spite of the very numerous researches on the nucleus which have lately appeared, must be regarded as still obscure. Sometimes the superficial portion of the cell-body may become hardened or otherwise altered, so as to form what is called a ' cell-wall,' but this is not to be regarded as a separate structure. In ceUs destined for special purposes the protoplasm be- comes modified. See Nuclbus in Affendix. Protoplasm is a nitrogenous, albuminous, colloid substance, having certain properties called vital, that is, the power of altering its form under the influence of stimuli, or, apparently, spontaneously. This power may be lost, under the influence of too powerful stimulation or other causes. Protoplasm does not appear to exist in the higher animals otherwise than in the form of minute masses or cells, but it would be rash to say that it cannot exist in continuous masses, as in certain forms of plants. Many of the properties of cells are the pro- perties of protoplasm. Those cells which con- sist of unmodified or nndiflferentiated proto- plasm possess contractility, the power of pro- truding their substance in the form of processes, of undergoing various changes of form, and even of locomotion. In these respects they resemble very simple animala—amceba, whose bodies are composed of homogeneous protoplasmic sub- stance, and these movements are hence called anueboid, or simply vital. Cells which, possess these properties may loss them, or die from excessive heat, cold, removal from the body, or other injurious influences. Hence the amceboid movements are especially characteristic of re- cently formed or young cells. They are seen in the white cells of the blood, lymph-corpuscles, the round or unfixed cells of connective tissue, the young cells which appear in inflamed parts, fresh pus-cells, and occasionally in the young cells of new growths, but are absent as a rule in cells highly differentiated and serving some special purpose, such as nerve-cells, secreting cells, and the fixed cells of connective tissue. Amoeboid cells are sometimes found in tissues to the fixed elements of which they have no relation, and are then to be regarded as emigrant or mi- gratory cells. They are very important in some pathological processes. CeU^rol^^ation, — Cells increase in number by fission, and perhaps, as some think, by gem- mation and by endogenous development. These processes collectively are called cell-prolifera- tion, which is doubtless the source of many of the new cells found in pathological states. All cells are not equally capable of proliferation, which is chiefly seen in amoeboid cells, and in aU the elements of connective tissue. This tissue was regarded by Virchow as the germinal tissue, from which all others originate, but the balance of opinion is now in favour of a different view, namely, that each kind of tissue, by prolifera- tion, produces only tissue of the same kind. He- cent researches show that cell-division takes place in two distinct modes, the direct and the indirect. iSee Nucleus. The mode of proliferation in epi- thelial cells is still imperfectly understood. It was formerly held by Schwann and others, that cells originated spontaneously in a homogeneous blastema; but proof is quite wanting of this mode of origin, and it is in accordance with all experience to believe that new cells are always the descendants of pre-existing cells — % con- clusion summarised by Virchow in th< words omms cellula e oelluld. It does not follow that new cells are always descended from the cells of the tissues in which they are foimd, since they may have emigrated from the blood-vessels. Shape of cells. — ^Amoeboid cells have, strictly speaking, no fixed shape ; but in a state of rest, and when dead, they are nearly spherical. Some cells of similar protoplasmic composition are very irregular in shape, and contain many nuclei, namely, myeloid or giant-cells. Other cells have various shapes, of which the commonest is an elongated form, with a process at each extremity, SB in fibre-cells; some, as nerve-cells or fixed connective-tissue cells, are stellate, with several processes. Some cells in certain new growths, especially tubercle, also .called giant-ceUs, hare extremely complicated processes. ! Wasting and Degeneration of eelU. — The ac tual duration of life in cells is not in all cases pre- cisely known ; but in the blood and in large collec- tions of amceboid cells we always find some with signs of decay and death, so that their life is probably measured by days. Epithelial and secreting cells have also a limited duration, while fixed cells of connective tissue and nerve cells are probably more permanent. Cells are also subject to the degenerations which affect tissues generally, especially the fatty, mu- cous, and colloid. The obvious pathological changes in organs are often due to the minute changes in the cells. Newly-formed cells are more subject, to degeneration and decay than the original elements; and this is espe ciaUy true of cells produced in inflammation. Some pathological processes consist essentially in the rapid production, followed by rapid 222 CELL. degeneration, of new cells, for example, scrofu- lous inflammation. Celhilar Patholo0.— This name is given to the system •which explains morbid processes by reference to the independent life of cells, their active properties, _ their proliferation, and their degenerations, while it attaches less im- portance to derangements of the circulation, or to alterations in the composition of the blood. Its foundations were laid by Eemak and Goodsir, but it was first reduced to u comprehensive system by Virchow, not only in his work thus named, but in memoirs published before and since. The cellular pathology explains many facts which were before obscure, and the iia'por- tant steps thus made are not likely to be retraced; but in several points modification of Virchow's views has become necessary. As to the origin of new-growths, it is not now held that all arise or can arise from the connective tissue; and in infiammation it is agreed that the changes of the tissues, however well-established, are only of subordinate importance, as compared with those depending upon the circulation. J. F. Patnb. CELLITIiITIS. — Dbpiottion. — Cellulitia is the term applied to inflammation of the cellular or loose connective tissue, whether the subcuta- neous areolar tissue, or that interposed between muscles and viscera, or surrounding various organs. The areolar connective tissue is so universally distributed throughout the body that it is neces- sarily concerned in most inflammations^no matter of what structure — and in it, in fact, the chief changes generally take place. To consider completely the pathology of in- flamed connective tissue would be more or less to review the whole series of the acute diseases. We must limit our consideration to cases in which the cellular tissue is the chief or only tissue involved, or where changes in other parts are secondary to those primarily affecting the cellular tissue. Beneath the skin, over the whole surface of the body, lies a layer of this tissue, containing within its meshes more or less adipose matter. It will be convenient to consider the changes which occur in it when inflamed, as they are iden- tical with those in cellular tissue elsewhere. Inflammation of the subcutaneous cellular tissue may be diffuse or ciroumscriied. The former is nearly always acute in type, and the latter often, but not invariably so. A chronic form of cellulitis causing thickenings is observed in various regions, or ic may be a sequel to the acute disease. 1. Circumscribed Cellulitis. — .Etiology. — Any injury to a part, whether of the nature of a wound or contusion ; an impacted foreign body ; or a fragment of bone, may cause cellulitis. Pyae- mia or septicaemia, any decomposing secretion in a, wound, altered blood, or infiltrated urine are prone to produce marked inflammatory changes in the connective tissue in different parts of the body. The poison introduced in a dissection- or poat-mortem wound often occasions an acute cellular inflammation. Frostbite, burns, inflammation of muscles, arteries, veins, or peri- CELLULITIS. osteum may produce inflammation of the adjacent ceUular tissue : thus, inflammation of the kidney may cause perinephritis ; inflammation of the uterus may lead to pelvic cellulitis; or some mischief in the greater bowel or rectum may produce inflammation and abscess in the looie cellular tissue around them (Periiy^UUia); tia poison also of scarlatina causes celiulitis of the submucous areolar tissue of the throat; and Angima, Ludwici is the name given to the cellulitis of the floor of the mouth and neck which is often associated with pysemic symptoms. A sympathetic buho is an irritated lymphatic glaud causing inflammation of the cellular tissue around it. Pathologt. — Pathologically, connective tissue is of the greatest importance in the organism, being the most frequent seat of inflammatory and other changes. Areolar tissue mainly cousistg of loosely interUced bundles of fibrous tissue, with fiattened connective-tissue corpusdes ad- herent to them, and leucocytes, or amcsboid corpuscles, in the intervals. The exact rbh played in infiammation by the cellular elements is not quite settled. Under ordinary circumstances the leucocytes doubtless proliferate, and the fixed corpuscles probably do so also. Even under the influence of a slight irritation the flattened corpuscles in a few hours become globular, and present many nuclei in their interior — changes certainly pointing towards proliferation ; while the very rapid increase of cells which takes place points to their derivation from cells pre-existing in the part, a,lthough the immigration of leuco- cytes from the blood into the inflamed part adds considerably to their numbers. Whether the perversion of nutrition which forms, the start- ing point of the disease first induces a local cell-proliferation, or an immigration of leuco- cytes, or what proportion these two processes bear to each other, is difiicult to determine. The disease consists essentially in a very active cell-proliferation and increase. Whether the cel- lulitis be circumscribed or diffuse, similar changes occur; the difference between them being that in the former there is formed a limitjcg zone of vascular tissue resembling granulation-material, which is absent when the inflammation is diffuse. There are other?rise no anatomical differences. When cellular tissue inflames, the part swells from the serofibrinous exudation poured out from the distended capillaries ; its meshes are filled with young round cells, partly by proliferation of the connective-tissue corpuscles, m part by the accumulation of wandering leucocytes ; the cir- culation is interfered with by the pressure of the effusion; complete stasis sometimes taking place. While the cell-increase is proceeding, the fibrillar intercellular substance gradually disappears, in part by necrosis, and in part by becoming liquefied ; and the tissue is finally transformed into pus. When this has happened the deeper layers of the skin disintegrate;. it becomes undermined, and gradually thinner; necrosis in one or more places follows ; and the pus mingled with shreds of dead cellular tissue escapes, the latter resembling nothing so much as soaked washleather. The pus, at fost thia and serous, subsequently becomes laudablt). There is always a groat tendency to siippn- CELLULITIS. 223 ration, the vitality of areolar tissue being very low ; but resolution sometimes takes place with- out formation of pus. The cells then develop into fibrous material and the ordinary pheno- mena of a cicatrix result. The consequences of cicatrisation diiFer greatly, according to the tissue or organ involved and the extent of the disease ; but essentially they are similar everywhere. A gradual contraction sets in. In external parts we can observe atrophic changes taking place, followed sometimes by defbrmity or loss of function, while in the viscera the condition is known as cirrhosis. The special tissue.of an organ or of a muscle cannot be reproduced ; it is replaced after an injury by connective-tissue cicatrix. In such tissues as bone, tendon, and nerve, however, the cicatrix will be converted into the normal tissue of the part. Symptoms. — The amount of fever varies with the extent of the disease and the nature of the cause ; when the cellulitis is quite limited there may be little or none, but deep-seated or ex- tensive cellulitis produces considerable constitu- tional disturbance. Painful swelling of tlie inflamed part will first be observed; the skin soon becomes tense, red, and oedematous, al- though at the outset it is sometimes paler than normal. The redness is gradually lost towards the periphery of the swelling, and is darker, or of a bluish-red tint in the centre, from the ob- struction to the exit of blood; the swelling is doughy, inelastic to the touch, and pits on pressure. The inflamed region feels hard, the induration ceasing by no well-defined border. If resolution occur all these symptoms subside. A greater or less amount of thickening of the tissue may, however, persist — often for a lengthened period — the parts gradually returning to t^eir normal state. Suppuration is, however, the rule ; and when it occurs the pain and tension dimi- nish, fiuctuation is felt, — obscure at first, — the pus by degrees approaching the surface, and escaping spontaneously, or by an artificial outlet which may bo provided. When the inflamma- tion is more deeply placed, especially when be- neath strong fascisB, there will at first be no perceptible redness or swelling of the skin, or only a slight pinkish hue, with some oedema, to indicate the changes taking place beneath ; and fiuctuation may be difficult or impossible to make out long after pus has formed; but the pain and fever are more considerable. This variety of the disease may also terminate in resolution — especially wlien early and appropriate treatment has been adopted ; or in suppuration. It may also become chronic, or relapses may take place after temporary amendment. If the cause of irritation be a slight one, but repeatedly re- newed, permanent thickenings or atrophic changes in the tissiie may result ; or the circumscribed may be converted into diffuse cellulitis. A very intense irritant sometimes induces gangrene. The same thing may happen if a previously diseased tissue be attacked, as an ailasarcous limb; or pressure, associated with the cel- lulitis preceding bed-sores, may be sufficient to cause it. 2. Diffuse Cellulitis. Stnok. : Biffiise phleg- mon ; Pseudo-erysipelas ; Diphtheria of the cellu- lar tissue. This is a severe disease attended by general symptoms of a marked character, fre- quently associated with septicemia, of which it may be both a cause and an effect. .^TioLooT. — The most frequent cause of diffusi cellulitis perhaps is some form of septic poisoning. In the extremities the disease may originatt from some trifling cause, especially in those whose constitution is impaired by age, privation, or excess ; in the hand and forearm of such persons it is especially common after wounds on the finger or an insignificant whitlow. In con- valescence from acute febrile diseases, espe- cially typhus or typhoid, a local phlegmon is sometimes transformed into a diifuse cellulitis. SiMPTOMs.— The local symptoms of diffuse cel- lulitis resemble those of the circumscribed form, but are more intense, and accompanied by severe constitutional disturbance. A sudden chill with elevation of temperature often ushers in the attack ; the rigor may recur at intervals, but sweating is unusual, and vomiting infrequent. In the affected region the patient experiences a sense of weight and great disten- sion, with severe dragging pain. When the inflammation is deep-seated the redness of the skin may not be well marked, even after a con- siderable extent of the cellular tissue has sloughed. This character is a very dangerous one, because it leads to the nature of the afifeetiOn being for a time overlooked and efficient aid postponed. When the sldn participates, the redness is darker in hue, less sharply defined, and less easily dis- persed by the pressure of the finger than in the cutaneous infiammation of erysipelas, while it soon becomes oedematous. The affected part feels brawny, hard, and swollen throughout, and extremely tender and painful ; sleep is impos- sible ; any movement causes great suifering; the fever is often very high ; the secretions are dimi- nished; and the appetite is lost. Sweating and rigor presently announce the formation of matter ; the swelling becomes less prominent and more soft ; the Skin is mottled, thinj and yielding in places ; and the fever and pain subside. Convales- cence may take place on the evacuation of the pus ; or the rigor may be renewed, the fever reappear or continue, and the patient sink with symptoms of ' blood-poisoning. The more deeply the in- fiammation extends the more tedious is recovery, and the more liable is the patient to relapse ; or the muscles, tendons, and adjacent joints- may become involved in tlie suppuration ; or perfora- tion of a dfingerous character of neighbouring cavities or organs may take place. Suppuration consequent upon diffuse cellnlar inflammation will sometimes extend up the fore-arm to the elbow, undermine the skin, dissect the muscles, open into the finger- and wrist-joints, cause necrosis of tendons, and terminate in the loss of the limb by amputation, or perhaps in loss of life from septic! poisoning ; should recovery ensue, the limb is permanently crippled from the mat- ting together of muscles and tendons, the immo- bilization of the joints, and the adhesions that take place between tissues which- should freely glide over one another. Suppuration is the rule, but under' favourable circumstances and with early and suitable treatment it may occasionally be prevented. Usually pus has already formed when the case comes under observation, and 224 CELLULITIS. the surgeon has only to use his bistoury to limit the spread of the disease. The irregular cavities and sinuses left after the evacuation of the dead tissue often suppurate for a long time, and may thus induce amyloid de- generation of the viscera. The thromboses which form of necessity in the smaller veins implicated in the inflamed area may break down and lead to septic embolism and_ pyaemia. The risk of this complication is a serious and ever-present one in these cases. DiAONOsis.— Cellulitis has chiefly to be diag- nosed from erysipelas. Erysipelas may involve the subcutaneous tissues, and cause inflammation and snppuiation of the connective tissue, but it always begins in the skin, which is more exten- sively affected. Inflammation of the cellular tissue begins beneath the skin, where the swell- ing and effusion first take place, the skin becom- ing involved later and usually to a less extent, while it may remain, at least ifor some time, almost entirely free; the redness, too, is less bright, and more difiiised, not presenting the distinct margins of erysipelas, but fading into the surrounding parts. In the later stages the two diseases are scarcely distinguishable. At first it may be difficult to decide whether the case is one of inflammation of the subcutaneous cellular tissue, of the perimuscular areolar tissue, or of that con- nected with the periosteum, or abound a vein. The greater the general swelling of the limb, the more considerable the fever and the pain, and the less the redness of the skin, the more probable is it that the inflammation affects deeply seated structures. FiujsNosis. — The prognosis depends on the extent of the disease and the constitution of the patient. Tbeatkent. — The local cause should be re- moved, so far as may be practicable. If the wound be in a foul condition it should be rendered aseptic. Absolute rest to the inflamed part is of great importance. So long as sup- puration has not occurred, resolution is pos- sible. Methodical pressure, once advocated, cannot usually be tolerated. Blistering is not employed in the acute form, but may be useful in removing more chropicchanges. Cold applica- tions and ice abate pain and inflammation, and limit the disease, even if they do not prevent suppuration. In the more advanced stages, es- pecially when they tend to become chronic, they are useless or even dangerous, &om their liability to cause gangrene in debilitated subjects. Local blood-letting does not prevent suppuration, and is usually contra-indicated by the weak state of the patient. When pus forms, or its presence is suspected, a sufficiently free outlet should be provided for it as soon as possible. Nothing so effectually checks the further spread of the disease. The incision should be made at the most prominent point. It is better to make a number of small incisions, from half an inch to an inch in length, than one long one, which is apt to be followed by dangerous bleeding, and does not relieve the strangulated tissues so efiicientljr. When suppuration is only sus- pected.incisions should nevertheless be practised without delay, without waiting for fluctuation. CEEEBELLUM, LESIONS OF. Pus and shreds of dead cellular tissue should be frequently washed out of the wound with an irrigator. No force should be used );q remove portions of dead tissue : any dragging teijds to rupture the small blood-vessels, and to destroy the remaining connexions of the skin with the deeper structures. Antiseptic precautions must be zealously carried out. When a joint becomes involved, or when the patient is thoroughly exhausted by the quantity of discharge, and the tissues spoiled, amputatiou is often necessary. Excision may be practised if the condition of the soft parts admits of it. Th8 general treatment consists in giving nourishing food and stimulants, cpmbined with opiates to relieve pain, and iron, quinine, and other tonic medicines. William MacCobmac. CEPHAIiAIiGIA (jce^mKii, the head, and i\yas, pain). — Pain in the head. See HEAnAcm. CEPHAIiH^aBMATOMA (ice0a\i,thehead; oT/*o, blood; and d/ihs, like). — Definition.— An effusion of blood occurring in newly-born infants, forming a tumour upon the head; situ- ated beneath the pericranium, upon the surface of the skull ; or more rarely beneath the skull, between it and the dura mater. Descbipiion. — This disease is of very rare occurrence, and must not be confounded with the caput succedaneuTtif which is an efiusion of serum external to the pericranium, and is of com- mon occurrence. The blood is generally extra- vasated immediately beneath the pericranium, over one of the parietal bones, most frequently the right, but it may occur over the frontal or occipital. Combined with this, or arising inde- pendently, but of extreme rarity, may be an effusion beneath the cranium. The origin of cephalhsematoma has been attributed to a variety of causes, but is most probably due to the constriction of the margin of the os uteri during labour. It is generally observed some hours or a day after birth, as a circumscribed swelling, slightly tense and fluctuating : and its peculiarity consists in a bony circle surrounding and limiting it. Diagnosis. — These tumours have been mis- taken for hernia cerebri, but their situation over the bone away from the fontanelles, the 'absence of pulsation, and the existence of fluctuation in cej^alhsematoma should prevent confusion. Pbognosis Generally the blood becomes ab- sorbed, but occasionally suppuration occurs, or the bone may become necrosed ; if beneath the skull, serious consequences, including idiocy, may ensue. Treatment. — As a rule, cephalhaematoma is not to be interfered with. If suppuration take place the pus must be evacuated. Clement Godson. CEBATITIS. See Kebatixis. CEEBEBELIiUM, Iiesions of.— The cere- bellum is liable to the same diseases as the brain and nerve-centres generally) such as hae- morrhage, abscess, various forms of degenera- tion, tumours, &o. The nature of the patholo- gical condition is to be determined by the symptoms peculiar to each, so far as this is pos- sible. Its locality in the cerebellum is to bo diagnosticated, first, by certain symptoms which CEREBELLUM, LESIONS OF. 226 are due to the. cerebellar lesion as such, which may be terra edtherfsrerf symptoms; and, secondly, by those symptoms which depend more on the influonce exerted by the lesion on neighbouring or subjacent centres and structures. These latter may be termed the indirect symptoms. It is by no means easy to separate these symptoms from each.other, and to say how much is due to interference with the functions of the cerebellum, and how much to interference with the functions of other parts. There are few diseases which have a purely local organic or functional limitation. Hence, in order to arriye at the symptoms peculiar to cerebellar lesions, it is necessary to exclude all pathological affec- tions which in their very nature afibct the whole of the intracranial centres, e.ff. tumours, menin- gitis, &c. The most satisfkotory conclusions from a pathological point of view are to be drawn from cases of atrophy or degeneration of the cerebellum, and, from a physiological point of view, from the results of experimental lesions of this organ in the lower animals. The evidence from these two sources is mu- tually supporting. DiEECT SYMPTOMS.— The characteristic symp- toms of cerebellar disease are disorders of equilibrium, shown, on attempts at locomotion, in a reeling or staggering gait (titubation), and a continual tendency to stumble or fall over the most trifling obstacle,' or on hurried movements. These symptoms may be confounded with locomotor ataxy, but careful observation will show that in cerebellar disorders there is no true ataxy of co-ordination. The movements are quite co-ordinated with each other,, and are Huch as would instinctively be made to prevent fall- j ing, or to preserve the equilibrium ; and have none of the precipitate, irregular, and sprawling character seen in ataxy. They are not specialljr intensified on closure of the eyes, which is such a marked feature in ataxy. Nor are they accom- panied by any of the sensory affections of ataxy, whether in the form of pains or aneesthesia. There is no true motor paralysis in cere- bellar disease as such, and the various volitional movements of the limbs can be carried out per- fectly well in the recumbent posture. Sensation, general and special, is not directly affected in cerebellar disease. Nystagmus and strabis- mus have been observed, more particularly in connection with lesion of the cerebellar pednncles. Defects of articulation have been noticed, but it is very doubtful whether they should be regarded as direct symptoms. It is to be noticed; that in some cases of slowly progressive degeneration of the cere- bellum, the disorders of equilibrium are not observed to any marked extent, an occurrence to be accounted for in all probability by compen- satory action on the part of other centres. Indirect Symptoms. — Pain in the head, more particularly at the back, though not constantly situated there^ is. frequently associated with organic disease of the cerebellum. Vomiting is also very frequently observed, perhaps ipore constantly, than in connection with diseases of other parts of the brain. There is, however, no reason to regard this as due to cerebellar disease as such. It is probably due 15 to indirect effects on the medulla, ^s a general rule, diseases tending to encroach on the space of theposterior fossa or to increase the pressure on thisregion, have a similar effect. Hemiplegia is not uncommon in connection with cerebellar disease, and more particularly in cases of tumour or haemorrhage into the lateral lobe of the cerebellum. The hemiplegia is on the side opposite the lesion. This does not prove that the hemiplegia is due to the destruction of the cerebellar lobe, or that the cerebellar lobes have cross relations with the limbs. Experimental physiology and anato- mical investigations tend^to show that the cere- bellar lobes are functionally related to the motor tracts on the same side. This is also borne out by the fact, that atrophy of the lateral lobe of the cerebellum follows disease and de- generation of the opposite cerebral hemisphere. The hemiplegia from cerebellar disease is, therefore, in all probability, due to compression or some affection of the subjacent motor tracts, whicli, decussate at the pyraniids; The fact that it occurs chiefly when the disease is limited to the lateral lobe is what might be expected on anatomical grounds. Affections of sensation, common and special, have been observed in cases of cerebellar dis- ease. Diminution of tactile sensation on the opposite side of the body, when the disease is situated in the lateral lobe,, is to be accounted for in the same way as the motor paralysis. A.i regards the special senses, affections of sight have be^u most frequently noted. Sight is cer- tainly not abolished by destruction of the cere- bellum in the lower animals, and when blindness occurs in man in connection with diseases of this organ, it is either due to implication of the corpora quadrigemina, functionally or or- ganically, or to secondary degeneration in the optic tracts, as the result of increasedintracranial pressure or descending optic neuritis. A special feature of tumours of the cerebellum, more especially of the middle lobe, is a tonic rigidity of the muscles of the back of the neck, with retraction of the head, associated frequently with flexion of the forearms and extension of the Iqvrer extremities and pointing of the toes. In these cases also, psychical, affections, more par- ticularly mental hebetude or stupor, occur as the result, of secondary dropsy of the ventricles, caused by pressure on the veins of Galen. The symptoms then become those of hydrocephalus., Haemorrhage into the middle lobe of the cere- bellum, in addition to the ordinary symptoms of apoplexy, has been frequently found to cause vascular excitement, of the genital organs — in the male marked jjnapjssra. This symptom, of which several cases were first reported'by Serres, led this observer . tq modify the view of Gall that the cerebellum, as a whole;, was related to the sexual instinct, and to regard the middle lobe only as having any such fuucjt^on. The facts, however, are susceptible of a totally different interpretation, and one more in har- mppy with other data of physiology and pa- thology. It has been found experimentally by Segalas and by Eekhard that irritation of the posterior surface of the med,ulla and pons giyes rise to vascular excitement of the generative 226 CEEEBELLTJM, LESIONS OF organs, and hence the eymptoms in cases of haemorrhage into the middle lobe are to he ascribed to irritation of this region. This fact also explains the absence of the symptoms when the haemorrhage occurs into the lateral lobes. There is absolutely no evidence of the slight- est value in support of Gall's liypothesis. The facts of clinical medicine go a considerable way in diametrical opposition to it, if they are not themselves sufioient entirely to overthrow it. Cerebellar Fedunclea. — Eespecting the effects of disease of the reetiform tracts or in- ferior cerebellar peduncles we have no definite knowledge. Cases, however, are on record in which lesions have been found involving principally either the superior or middle cerebellar peduncles. The symptoms, in the main, agree with those observed by Magendie on section of the middle peduncle in the lower animals. The chief effect of this lesion was to cause an irresistible ten- dency to roll over towards the side of lesion. Together with this rotatory disturbance of the equilibrium, a peculiar distortion of the optic axes was observed, the eye on the side of lesion being directed downwards and inwards, the other looking upwards and outwards. In a case described by Curschmann (JDmtach. Archiv f. Klin. Med. xii. 3S6), along with appearances of basilar meningitis, wbich some- what complicate the case, there was found a focus of softening, surrounded by capillary haemorrhages in uie right superior cerebellar peduncle. The symptoms observed in this case were a rotatory distortion to the right side, to which position the patient invariably returned when resistance to this movement was with- drawn. There was no motor paralysis, nor was there any distortion of the optic axes. A case has been put on record by Nonat (Comptes Seadtie, 181) of apoplectic extrava-' aation into the right middle peduncle of the cerebellum and right cerebellar hemisphere. In this case the head and trunk were twietod towards the right side, and the ocular symp- toms were also present, the eyes being immovable in a position of skew deviation. Other cases are on record in which the cerebellar peduncles have been involved in more extensive lesions ; but the symptoms, though not opposed to those above related, are incapable of differential analysis. The special diagnostic symptoms, therefore, of lesion of the cerebellar peduncles are what are frequently termed ' forced move- ments ' {Zmangabewegungen), or distortions of the normal axis of the trunk. The exact direc- tion of the distortion, in consequence of lesion specially limited to one or other peduncle on the right or left side respectively, is somewhat doubtful, though as a rule it has been found to- wards the side of lesion. Much, however, will depend on whether the lesion is of an irritative or inflammatory, or of a destructive character. A lesion of an irritative nature, though bccupy- ihg the same position as a destructive lesion, would exactly reverse the direction of the dis- tortion of the head and trunk. D. Fbbbier. OSBElBBAIi ABSCESS. See Bbadt, Ab- tKtiSS of. CEEEBEO-SPINAL FEVBE. CEBEBBAL APOPLBXT. SeekvoYusst, Cerebral. CEBEBBAXi ABTEBIES, Diseases of. See Bbain, Vessels of. Diseases of. CEBEBBAIi BLZElMOBBHAaE. Bee Bbain, Haemorrhage into, CEBEBBITIS. — ^Inflammation of the brain- substance. See Bbain, Inflammation of. ' CEBBBEO-SPIITAIi FBVEB.— SvifON. : Epidemic Cerebro-spinal Meningitis; The Black Sickness (popular, Dublin) ; Fr. Meningite cirehro- spitiale ipidemique i Ger. Cerebral-typhus; Epi- Definition. — An acute epidemic febrile dis- ease, characterised by sudden invasion, with extreme nervous shock, vomiting, excessive pain referred to the back of the neck and spinOj spas- modic contraction of muscles, excessive sensibi- lity of the skin, and frequently delirimn ; accom- panied by purpuric eruptions, either circum- scribed, raised, hard, and shotty to the, feel, or extensive purpuric spots or patches, fre- quently accompanied by vesicular eruptions usu- ally of herpetic but sometimes of a pemphigoid character, and frequently purulent inflammation of the eyes. Post morion there are found: inflammation of the membranes of the brain and spinal cord, especially of the arachnoid, with deposit of white, yello* or greeniSh-yellow lymph upon the surface of the arachnoid, espe- cially 'at the base of the brain and anterior portion of the medulla oblongata and spinal cord, and effusion of serum into the ventricles and sub-arachnoid spaces. Mtvsuia-z.^Age. — The disease usuallyattacks those approaching the age of puberty or in early adult life ; it is seldom met with after thirty-five years, and is very rare after the age of forty. It is not unfrequent in young children. Sex — It is much more frequent in males tlaa females ; robust males between the ages of fifteen and thirty are its favourite victims. Occupation, — It' seems specially to attack young recruits in the army, as was the case in the French epidemics. In Dublin it was specially severe among the recruits of the Eoyal Irish Constabulary stationed in the police barracks in the Phoenix Park. There does not seem to be any other occupation which predisposes to the disease. Excessive fatigue seems to predispose to the disease ; it has arisen after a hard day's hunting, foot-racing, long walks, dancing,! or in children exhausted from out-door play. ■ Season and Climate.— It is widely distributed in the_ temperate zone. It prevails more in cold than in hot weather ; in Iceland it has usually prevailed in winter and early spring. General Sanitary Conditions.— It seems to be less influenced than any other epidemic affection by general sajnitary conditions. ' CemTimnioability.— It is generally believed not to be contagious ; a few doubtful cases of con- tagion have been recorded ; except, however, in cases where it has appeared as an epidemic among recruits, there are few instances of mora than one case arising in any particular house of circumscribed locality. Epidemic Influence.— The disease is nndoubt edly epidemic. OEREBRO-SPINAL' FEVER. 227 IMwholesome Food.—li has been suggested that the disease owes its origin to the use of brcadstnffs made from diseased grain. _ Ahatomica^i. Charaoteks. — Cadaveric rigidity- is -well marked; large purpuric patches form after death even in cases where there ■were no purpuric symptoms during life; in some cases the whole body has turned black. On incision a large quantity of dark, tarry-looking blood exudes ; the muscles are darker than usual, and in prolonged cases much weakened and wasted, Tliere is increased vascularity of the scalp ; the cerebral sinuses are much distended with dark blood ; serum is found in the sub-araohnoid spaces and ventricles ; all the membranes of the brain may be more or less congested, the arachnoid being always extremely vascular and opaque from deposits oi" lymph —this opacity varies from slight milkinoss to thick and dense deposits. The most marked intracranial lesion is the white-yellowish or yelloinsh-green 'flbriho-purulent' deposit found at the base of the brain. This deposit varies somewhat with the duration of the disease : in cases which die early the deposit is usually slight, whitish, and soft ; in those which live for a week or so the deposit is yellowish or greenish ; in prolonged eases the deposit is more white and pure, the eifused serum greater in quantity, and the vascular fiilness less. The origins of the nerves seem to be buried in and compressed by the deposit. The brain-substance itself is more vascular than normal, but not otherwise altered. In the sjnnal eord tlie lesions are similar to those found in the brain and its membranes^ In some eases purulent infiltration of the eye- ball and effusion into the joints have been met with. The lungs, liver, and spleen have been found much congested in many cases. Symptoms. — The patient is usually attacked suddenly when in apparently vigorous health by faintness, vomiting of greenish matter, and in- tense pain referred especially to the back of the head and neck ; the extremities become cold ; the patient becomes insensible and sometimes con- vulsed ; the limbs become rigid. On recovering from the collapse, the patient complains of great pain in the head, back of neck, and along the spine ; the head is drawn back, so as to be almost at a right angle with the spine; the whole back is sometimes arched, as in tetanus, the muscles become rigid, and the skin excessively sensitive ; neuralgic pains are also complained of in all :parts of the body. In most of the severe cases erup- tions appear within the first twenty-four hours ; the eruption usually appears first on the legs, and is frequently confined to the lower extremi- ties ; the spots are usually black, raised, about a line in breadth, and feel like a grain of shot under the skin; sometimes these Taised spots are eiurrouuded by a darb purplish areola ; in most cases large purpuric patches of many inches in extent form on various parta and, sometimes coalescing, cover the entire body. Vesicular eruptions are also common; these usually have the character of herpes zoster, and are most frequent on the face, neck, and shoulders. The herpeijc eruptions are met with as frequently in mild as in severe cases. Pem- phigus sometimes appears in the advanced stages of t^e disease. When reaction sets in, the tem- perature is found to have risen to from 100° to 103° or IOi° Fahr. In many cases the tem- perature never rises, and the patient dies in the collapse ; the respiration becomes of a • sighing character ; the pulse rises to about 120, and has a peculiar jerking character, giving a sharp up ■ stroke to a sphygmographic tracing,' The fore- going symptoms are very variable ; any one, or even a considerable number of them; may be absent throughout the whole course of the case. CoMPUCATioNs AND Seoubue, — Complica- tions connected with the nervous system axe the most common ; paralysis of one or more limbs is common, of a hemiplegia character, and most frequently attacking the arm ; deafness is not very common, but has been met with in several cases, and sometimes becomes perma- nent. The eye-complications are among the most frequent and most serious. The eye is frequently attacked with a low form of inflam- mation, terminating in purulent infiltration of the whole or part of the organ ; the cornea is more frequently attacked than any other por- tion ; and this sometimes giving way, the whole contents of the globe escape^ causing perma- nent loss of sight. The sight is also often per- manently impaired by iritis, or opacity of the cornea. In many cases, however, the inflamma- tion completety subsides. It is remarkable that it is the right eye which is usually attacked, seldom that both eyes are affected, and scarcely ever the left eye alone. Acute inflammation of the larger joints is a frequent complication in some epidemics ; this often terminates in puru- lent effusion into the joints. Haemorrhages are frequent in the more malignant forms, and are almost always present in cases where the purpuric blotches are of large extent; these hsemorrhages have occurred from the nose, uterus, bowels, kidneys, and ears in about the foregoing order of frequency. Gangrene is occa- sionally met with, and the cases in which it occurs are usually fatal. In some cases toes have been lost and the patient recovered; the purpuric patches have also sloughed without serious danger to the patient's life. DuQNOSis.-^The disease is liable to be con- founded vrith typhus fever on account of the petechial rash, but is distinguished from typhus by the rash appearing suddenly without any previous mottling of the skin. The nervous symp- toms also distinguish it from typhus,ialthough in a case of typhus complicated with cerebro- spinal' meningitis the diagnosis is extremely difficult, and may be impossible. It is distin- guished from pwrpwra hemorrhagica by the in- tensity of the fever and the localised nervous symptoms. The malignant cases are more likely to be mistaken for malignant scarlatina than for any other disease, and must be distinguished therefrom by the rash, soro throat, and nervous affections. In some cases it has been indistin- guishable from malignant scarlatina, especially where death occurred within twenty-four hours, and both diseases were epidemic at the time. Pkoonosis, DnKATioif, Tebmination, Am) Mortality. — The prognosisi duration, etc., of the disease depend much upon the form the affection assumes, and for convenience we .may divide the disease into the follovring forms : — 228 CEEEBRO-SPINAL FEVEE. 1st. Cases of a reiy mild form, terminating in recorery; the duration being usually from one to three weeks. 2nd. Cases of » very severe form, setting in suddenly; the symptoms being very violent and ■well marked, accompanied by purpuric spots and blotches, with a tendency to haemorrhages, with deep collapse and coma ; usually terminating fatally in from a few hours to three days. 3rd. Cases of medium severity, where all the nervous symptoms set in with less suddenness than in the second class of cases, purpuric blotches not being usually present, and no hse- morrhages. These usually yield to treatment, and terminate in recovery in from two to six weeks. 4th. Cases which set-in either in a mild or in a severe form, but in which on the subsidence of the fever the strength does not return, con- valescence is retarded or ceases altogether, and the patient falls into a general atrophic condi- tion, and usually dies in from three to six months of marasmus. By deciding to which of the above classes the case belongs, the prognosis will be to a great extent determined. The chief indication of danger is the early appearance of purpuric and haemoirhagic conditions. The mortality in cerebro-spinal fever is very high — probably on an average about 60 per cent. In some of the American epidemics it is placed as high as 75 per cent, ^jnong the Irish con- stabulary it reached 80 per cent. Like other epidemic diseases the mortality is highest at the commencement of the epidemic. It is most fatal about the age of twenty, and less so under fifteen years. Treatment. — The treatment in the early stage must be directed to recovering the patient from the collapse. This is best done by the application of beat, the administration of small quantities of stimulants or stimulating enemata. and the appli- cation of sinapisms over chest and back. In the next stage of the disease attention must be almost altogether directed to allaying the spinal irrita- tion, and promoting the absorption of the efliised matters. The extreme irritation will be best diminished by the use of belladonna and bromide of potassium. The pain, which is extreme, will yield best to frequent and considerable doses of opium ; indeed many physicians rely altogether on opium as the curative agent. With a view of promoting absorption of the effused matters, mercury and iodide of potassium have been chiefly relied upon. In the more sthenic cases calomel may be employed with benefit in small and repeated doses.. The disease being usually of an asthenic type, mercury will seldom be well borne, and iodide of potassium should be pre- ferred. Leeches applied to the back of the neck, behind the ears, or to the temples, produce great rnlief of the excessive pain in the head and upper part of the spine. The application of ice to the head and spine temporarily allays pain, but there is little evidence of permanent benefit being derived therefrom. In prolonged cases blisters applied along the spine have been favourably spoken of The local complications must be treated as they arise, and according to general principles applicable in each case. CHANGE OF LIFE. Stimulants are required in considerable qaan. tity in a very large number of the cases which present adynamic symptoms. T. W. Geimshaw. CH All AZIOIT (xei^afo, hail). — A small en- cysted tumour of the eyelids, colourless and transparent, and resembling a hailstone. OHAIiK-STOlTES. — This name is applied to the deposits which are formed in connexion with the gouty diathesis, especially in the joints. They are thus denominated from their appear- ance and physical characters, in which they more or less resemble chalk ; but in their chemical composition they are entirely different, consist- ing mainly of urate of soda. See Gout. OH ALTBEATB 'WATEES (chalt/hs, steel). — Mineral waters which contain iron. Bee MiNEBAi, Watebs. CHAIfCBE (Fr. chancre). — Hard chancre is the initial manifestation of syphilis. See Syphilis. Soft chancre, see Venereal Disease. OHANGE or LIFE. — Stkok. : Climacteric epoch ; Sexual involution ; Fr. Meaopattse.' &er. Menstruationsende. Definition. — The time of life in a woman when the functions of the uterus and ovaries cease, menstruation terminating, — a period when disease of these organs is especially prone to occur, aiid when various constitutional disturb- ances are almost certain to arise. Anatomical Chabactebs. — Great changes oor cur in the sexual organs — the ovaries lose their smooth outline, and after a while become shri- velled up, occasionally only a trace of them re- maining ; the Fallopian tubes diminish in size, and sometimes become obliterated ; the walls of the uterus atrophy, its cavity becomes much smaller, and the cervix disappears altogether. Symptoms. — The term 'change of life' is used among women very widely to signify every- thing which affects them at this critical time. It is so rare for the transition from activity to in< activity to take place without some disturbance locally, or constitutionally, that women are apt to neglect seeking advice for symptoms which should demand careful treatment, believing as they do that it is natural to suffer in such ways at 'the change.' There is no fixed period for the climacteric epoch, though roughly it may be said to occur between the ages of forty-five and fifty. Certain causes are apt to determine the time — amongst these are parturition and lacta- tion, febrile attacks^ such as typhus or acute rheumatism, profuse hsemorrhages, fright, &e. The symptoms vary much. In some women the change is abrupt, menstruation ceasing all at once after perfect regularity ; in others, and more frequently, the change is prolonged, the catamenia being irregular for many months, and varying as to periodicity and quantity. Frequently, after a long interval, a profuse flow with clots occurs, and this is very often attri- buted to a miscarriage. This loss is frequently beneficial, and if it do not take place, or relief be derived from vicarious discharges, su6h as bleedings from hsemorrhoids, the excess of blood gives rise to headaches, flushes, vertigo, and a host of other unpleasant symptoms. The CHANGE OF LIFE, balance between the nervous and circu4tory systems is up^et; irritability of temper, hyper- sensitiveness and all sorts of fancies arise, or de- pression sometimes amounting to melancholia en- sues. If germs of disease exist, the uterus is espe- cially prone at such time to develop them, so that carcinoma, fibroid disease, and polypus frequently present their first symptoms at this epoch. The importance, therefore, of an early examination cannot be too forcibly dwelt on, or the mischief of delay from considering the abnormal condition as typical of ' the change of life,' as a natural consequence, which will therefore right itself. At these times pruritus of the vulva, vascular growths at the orifice of the urethra, and cuta- neous eruptions are especially likely to occur. There is a teidency to grow fat, and become coarse ; frequently hairs appear on the face. The breasts often become veiy large and pendulous, and this with the increase in the sfee of the ab- domen from flatus, and the deposition of fat in its walls, together with the cessation of menstru- ation, not infrequently gives rise to the supposi- tion of pregLanoy. To this jmagiiiary state the term Pseudooyesis has been applied', and it is often almost impossible to set aside the opinion of the woman regarding her supposed condition. The headaches, neuralgia, loss of memory and nervous symptoms appear to be due to disturb- ance in the giinglionic system of nerves, with which the uterus and ovaries are largely sup- plied. If insanity arise the most commnn form t assumes is hypochondriasis or melancholia. TaEiTMENT. — This must be directed to regu- lating the secretions. Generally constipation, previiiusly troublesome, becomes aggravated ; and portal congestion frequently occurs. Saliiie pur- gatives are especially beneScial, and these may be judiciously administered in the form of mine- ral waters, such as the Hunyadi Janos, or Fried- richshall. Blue pill with aloes is often very useful. The headaches and reflex nervous symp- toms may be best combated by tlie administration of bromide of potassium, and this drug appears to act as a direct sedative to the sexual organs, besides diminishing the amount of blood deter- mined to them. Occasionally, bleeding from the arm or cupping gives great relief. Attention must above all be paid to the diet. It should be plain and unstimulating ; beer and spirits should be prohibited, and only light wines, if any , allowed. Tepid baths are useful. Late hours, heated rooms, and excitement of all kinds should be avoided. If local troubles arise, they must be treated ac- cording to their indications ; as a rule, abstracting blood from the uterus does harm, but leeches to the anns are sometimes beneficial.' It is clearly impossible to map out any empirical line of trea.t- ment for a condition in which the symptoms are so variable. Clement Godsok, CHAPPED ITIPPLBS. See Bbeast, Dis- eases of ; and Nipple, Diseases Of. CHAPS.— Synon. : Ehagades. — Cracks or fissures of the skin occur where ' the irtegu- ment has become ha,rdened by infiltration, as in the erythema of the hands and wrists of cold wenther, in chronic eczema, psoriasis and lepra vulgaris. The treatment for chaps consists in OHELOID. 229 protection from the atmosphere; oarefhl dry- ing after the hands have been washed or wetted ; and the use of zinc ointment and glycerine soap. Diluted glycerine, vaseline, and cold cream are also popidar remedies. Eeasmus Wilson. OHELOID (xi^J(> a claw). — Synon. : Cho- loides, Oheloma ; Fr. Dartre de la graisse ; Ger. Keloid. Definition. — A tumour of the skin resulting from over-growth of connective tissue within the oorium. .Etiology. — Cheloma may be idiopathic or accidental, and in both cases it is referrible to a diathesis. ' When of accidental origin it is commonly associated with a cicatrix, and is th^n developed in the midst of the cicatrix-tissue. This form of the tumour has been denominated chdoides spuria or traumatica, and, as such, has been seen scattered numerously over the chest and shoulders as a sequel of acne. The cause of cheloma must be sought for in that vital source from which is derived aberra- tion of nutrition in general. It is a consequence of feeble controlling power, and may be resident in the skin alone, or be dependent on a want of vigour of the constitution of the individual. The traumatic cheloid may follow a light as well as a severe injury of the skin, such as a boil, ' a blister, a leech-bite, or even the ir- ritation of a stimulating liniment ; it is some- times met with in' the scars of strumius abscesses or ulcers, but is most common in the cicatrices of burns or scalds. Anatomical Chabacibbs. — At its first de- velopment cheloma occupies the fibrous portion of the corium. As it increases in bulk it pushes the vascular layer outwards and' stiretches the corpus papiUare, obliterating the capil- lary network, more or less completely. In its aggregate form' when it presents itself as a flai; plate, raised for a quarter of an inch above the level of the adjoining skin and sinking to a similar extent into the corium, it has the appear- ance of being tifed down by strong cords or roots at either end, and frequently overlaps the healthy skin along its borders. In this state it is seen to be composed of strong fibrous bands closely interlaced with each other and enveloped by a smooth transparent pinkish layer, in which may be detected a scanty vascular plexus converging to venules which sink between the meshes of the fibrous structure. Around the circumference of one of these larger flattened tumours, such as is commonly met with on the sternum, and measuringseveral inches in diameter, there will generally be observed a few scattered knots. These are developed in the fibrous sheath of the arteries at a short distance from the mass, and, being thus linked to the central growth, are subsequently dra-wn into the focus of the tumour. And the development of the so-called roots is explained by the propagation of the proliferating process by the coats and sheaths of the blood-vessels communicating with the central tumour. Descbiption.— Cheloid has received its name from its habit of throwing out spurs from its circumference, these spurs having been com- pared to crab's claws. It originates in a round. 230 CHELOID. oval, or oblong tubercle or knot in the skin, and this may be followed by a second in its imme- diate neigbbonrhood, or someti mes by a cluster of three or four. When two of these knots are situ- ated at a short distance apart they are apt to become connected by a cord of the same structure as themselves, and to give rise to ■what has been called a ct/liniirical, club-shaped, or dumb-hell cheioid. When three or four knots are grouped near together they are disposed to become blended by growth and produce an oval or square-shaped oheloid ; and when the growth eitends from these latter into the sur- rounding integument the appearance denominated radiciformis is established. . Cheloma being due to a tendency to overgrowth or hyperplasia of connective tissue within the skin, it may appear on several parts of the integument at the same time, one of the most common seats of its development being the sternum, which it generally crosses transversely. It is often solitary; is more commonly composed of five or six tumours, discrete or confluent ; but has been met with occasionally to the number of fifty or sixty tubercles or more. Coras B AND FBoaHosis. — Oheloid rarely gives rise to much inconvenience or attains any con- siderable magnitude, and when left to itself progresses very slowly or remains stationary for a number of years or for life; and we have known it to disappear spontaneously. Its sub- jective symptoms are ct no great severity, being limited to itching, tingling, and smarting, and more or less uneasiness in moving the limbs, or from pressure when sitting or lying in bed. It has no tendency to desquamation or ulcera- tion. Tbbatmbnt. — Being dependent on a diathesis, surgical manipulation has generally proved un- availing in cheloma, It might be expected to recur in tlio cicatrix of a wound niade for its removal, or in the scars of a suture employed to hold the cut edges together, and such has proved to be the case.' The most successful treatment consists in covering up the tumour with a mercu- rial or iodine plaster, or even with, simple em- plastrum plumbi. The writer's favourite treat- ment is. to paint it with a spirituous solution of soap and iodide of potassium, and then cover it with an adhesive plaster spread on washleather, repeating the application as often as the plaster becomes loosened. We have seen a multiple cheloma cured in this way ; aided by mild doses of the perehloride pf mercury. The combination of warmth and moisture, such as is produced by a plaster, is an important element in the cure. But irritants, caustics, and the knife are all equally objectionable and valueless. Erasmus Wilson. CHELTENHAM, in Gloucestershire. Common salt waters. See Minebal Waters. CHEMOSIS (xV)/»77, a hole).^A swollen con- dition of the conjunctiva, caused by effusion into its tissue around the cornea, which thus appears as if placed in a hole or hollow. See Eye and its Appendages, Diseases of. CHEST, Diseases of the.— Following the plan adopted in the general article on the Abdo- CHEST, DISEASES OF THR men,* is proposed in the first place to give an outline of the diseases of the chest ; and then to indicate the principal points bearing on their clinical investigation. General Scmmabi. — The diseases of the thorax and its contents may be conveniently divided into certain groups, namely : — I. Diseases of the chest-walls, or extending inwards from these walls. II. Diseases of the respiratory apparatus con- tained within the thorax, namely : — 1. PleiMse. 2. Trachea. 3. Main Bronchi. 4. Lungs. III. Diseases connected with the circulatory system, including : — 1. Pericardium. 2. Heart. 3. Great vessels within the chest, both arteries and veins. lY. Diseases originating in the mediastinal cellular tissue. v. Diseases of the absorbent vessels or glands within the chest ; of the thoracic duct ; and of the thymus gland or its remains. VI. Diseases of the oesophagus. VII. Diseases of either of the important nerves traversing the chest. VIII. Diseases of the diaphragm. IX. Diseases encroaching upon the chest from the abdomen or from the neck. The particular diseases comprehended within most of the groups just enumerated are very numerous, and they will be described under their respective articles. Affections connected with the chest constitute a large proportion of the cases which come under observation m prac- tice. This will be readily understood when we remember that the thorax encloses organs essen- tial to hfe, which are never at rest, and which are constantly more or less exposed to influences liable to injure them. They may be mere/ww- tional disorders, and to these the heart is espe- cially prone; but senona orffamo diseases &ve ako exceedingly common, and rank very high as causes of death. Moreover, they may either come under the category of -local affections, though even then they frequently depend upon some cause acting through the general system, such as exposure to cold or wet ; or they arise in the course of some general malady. For instance, pulmonary com- plications are of common occurrence in connexion with fevers and various other diseases; the heart is implicated in a large proportion of cases of rheumatic fever; and malignant disease is not infrequently manifested by a local development of cancer in connexion with certain of the thoracic contents. The structures within the chest have an important mutual influence upon each other; and they may also be affected, either directly or indirectly, by local diseases involving other parts of the body, sUch as the abdomen or the central nervous system. Clinical Investigation. — It may be confi- dently ainrmed, that the means which we now possess for investigating diseases connected with the chest are so adequate and precise, that anj one possessing the requisite knowledge and skill, and who carries out the clinical examinaitibn pro- perly, can, in the very large majority of cases, arrive at a diagnosis with certainty and accuracy. At the same time it must be remembered that every complaint referred to this region, howevel trivial it may appear to be, does require system- CHEST, DISEASES OP THE. atic. and thorough investigation, otherwise very ■erioua mistakes are constantly liable tobe made. Of course,, cases also do come under observation occasionally which are obscure, and which may call for repeated examination before a correct diagnosis can be formed; and exceptional in- stances occur in which no satisfactory conclusion can be arrived at. The previous general history of the patient, the hereditary history, and the account of the origin and progress of the iUness, often afford signal. aid in the investigation of chest-affeotions, and oughtnever to be overlooked. The symptoms to which these aflfeotions give rise are necessarily various. Fain or other morbid sensations ace very commonly complained of, but only in a comparatively few instances are these at all sigmficant, and they can never be posi- tively rehed upon in making a diagnosis, while they are often absent in diseases of the most serious character. The important organs, namely, the lungs and heart, usually present more or less disturbance of their functions when they are affected, but grave diseases may exist without any such disturbance. The different stmctares within the chest have a mutual influence upon each other, and thus other symptoms besides those connected with the structure actually diseased maybe apparent. For instance, the lungs and heart are thus very intimately associated ; while anfeiirisms or growths often disturb these organs ssrionsly, or interfere with the air-tubes, nerves, veins, and other structures. In consequence of more or less interference with the, circulation, various symptoms in parts remote from the chest are frequently originated; and distant organs may become the seat of organic lesions as the result of long-continued mechanical conges- tion, a new train of symptoms being thus set up. The general system may be in this manner af- fected ; whilst pyrexia, wasting, and other general symptoms are often associated with chest-diseases. LasUy, morbid conditions within the thorax may directly affect the abdominal organs; or may make their way through the diaphragm into the abdominal cavity. Physical Examination constitutes an essential and most important part of the clinical investiga- tion of the chest and its contents. Indeed, with- out this examination no certain and exact diag- nosis can ever be made. This subject is fully discussed in other appropriate articles, and bore it need only be mentioned that the methods of examination which are usually required,, and which should in every case be practised, are : — 1. Inspection. 2. Palpation. 3. Ptrcussion^ i. Auscultation. Other modes which may be called for include: — 5. Measurement (not uncommonly). 6. Succussion. 7. The use of special instruments, directed to ihe investigation of particular organs, such as the spirometer, cardiograph, sphygmo- graph, aspirateur, oesophageal bougie, &c. See Physical Examination, and Diseases of the several organs. Ekbdebick T. Eobeets. CHEST, Examination of. Examination. See Phisicai CHE ST-"W ALLS, Morbid Conditions of. — The walls of the chest may be the seat of various morbid conditions, and the affections CHEST-WALLS. 231 of this portion of the framework of the body de- mand more attention than they are accustomed to receive. All that can be done within the limits of this article is to indicate their nature ; to notice briefly such of them as are not de- scribed in other parts of this volume ; and to point out the principles of treatment. Thej c^ay be considered according to the following arrange- ment : — 1. Superficial Affections.— Under this gi-oup may be included morbid conditions of the skin and subcutaneous tissues, a. Cutaneous erup- tions are of common occurrence over the chest. Among these may be specially mentioned the eruptions of the exanthemata, herpes zoster, and chloasma, 4, The superficial vessels are liable to become enlarged under certain circumstances. This enlargement is usually seen in the veins over the front of the thorax, which may be distended on both sides, or only on one side, or in some particular region. The laiger divisions may alone appear to be involved ; or a more or less exten- sive network of smaller veins may be visible, and occasionally even the capillaries seem to be im- plicated. This condition generally arises from some obstruction interfering with the circulation through one or other of the principal veins which, either directly or indirectly, receive the blood from the veins of the thoracic wall. Thus the superior vena cava, or either innominate, sub- clavian, or axillary may be implicated, being, for example, pressed upon by new growths or en- larged glands, the distribution and extent of the venous distension varying accordingly. Occasion- ally one of the smaller veins is thus interfered with. The writer has met with cases jn which considerable enlargement of the veins was visible over portions of the thgrax.Therethe cause was by no means evident, the patients asserting that this condition bad existed ever since they could re- member, and being regarded by them as perfectly : normal. Probably it has resulted from some local obstruction occurring during early life. It must be remembered that women who are suckling frequently present great enlargement of the su- perficial veins over the front of the chest, which usually subsides when the period of lactation is at an end. Again, more or less venous and capil- lary engorgement in this region may occasionally be observed in cases of cardiac or pulmonary disease, where the general circulation is much im- peded, and due aeration of the blood is interfered with. Sometinies a ring of enlarged veins and capillaries is seen around the lower part of the chest. "When the venous distension is due to ob- struction of the vena cava superior, the skin may present a rjore or less marked cyanotic tint, and in eases of general cyanosis, the chest, in common with other parts, -has a cyanotic appearance. Occasionally one or other of the small arteries which supply the thoracic walls is enlarged, and it may attain a considerable size. , c. Subcutaneous oedema is sometimes observed over the chest. In most instances this is a local condition, being the result of venous obstruction ; but it may be a part of general dropsy, particularly in connexion with renal disease. This morbid state is evident on inspection or to the touch, and the affected part pits on pressure, d. The subcutaneous tissue of the therax is also liable to become the seat of 232 so-ealled emphysema, as the result of perforation or rupture of the lung and pleura, with the consequent escape of air into the cellular tissue under the skin, where it accumulates, and travels to a greater or less extent over the body. _ The lung may also give way into the mediastinum, the air which escapes subsequently making its way from this part into the subcutaneous tissue. This condition is generally due to direct injury, especially from fractured ribs, but it may also arise, in exceptional instances, from other causes, such as violent cough,powerful expiratory eiforts, as in parturition, pulmonary disease — for in- stance, the giving way of a cavity in the luhg^— or in connexion with empyaema. Subcutaneous em- physema is attended with evid.ent swelling of the part, which may be very great, all the normal ana- tomical outlines being obliterated; the peculiar sensation accompanying this condition is readily elicited on palpation and percussion ; the percus- sion sound is tytnpanitic ; and on auscultation a Buperficial crackling sound is heard, e. As be- longing to the sv.perficial affections connected with the chest may be just mentioned diseases of the mammary gland or nipple, which of course constitute a most important class of diseases in females (see BnniST, Diseases of). 2. Muscular and Tendinous Affections. — a. The muscles of the chest or their tendinous attachments may be the seat of certain painful affections. These are of the nature of so-called muscular rheumatism or myalgia, of inflamma- tion, or of more or less injury or strain ; being induced by cold, constitutional conditions such as gout, overwork, straining, violent coughing, fatigue from prolonged sitting, and other causes. The painful condition is usually localized, but different muscles are involved in different cases, sometimes those which are superficial being affected, in others the deeper muscles including the intercostals ; or the complaint may be confined to a single muscle. PlouTodynia, dorsodynia, and Boapulodynia are the terms applied to muscular rheumatism affecting the side of the chest, the upper part of the back, and the scapular regions respectively. As tlio result of severe coughing, muscular pains aro veiy common around the lower part of the chest. The pain is usually more or less aching in character, and not severe, but it may be very intense, especially in acute cases. Whatever bringi the affected muscles into play aggravates the suffering, such as moving the arms or shoulders when the superficial muscles are affected, coughing, sneezing, and similar actions. In some instances the pain is not felt when the affectel structures are kept quite at rest. There may be local tenderness on pressure, or diffused pressure may give relief; while posture often influences the sensations experienced, such as whether the patient assumes the recumbent or sitting posture, or lies on one or other side. Fatigue generally increases the pain. Muscular affections connected with the chest are not neces- sarily accompanied with any other local symp^ toms ; and physical examination reveals nothing, except that perhaps the act of breathing is volun- tarily restrained, on account of the pain thus in- duced, b. Themusclesofthechestmay beaffected, on the one hand, with spasm or cramp ; on the other, with paralysis. The former is attended CHEST-WALLS, MOBBID CONDITIONS OF. with more or less pain, which may be vei^ severe; the latter is indicated by loss of power in the muscles involved. These disorders genie rally depend on some lesion of the central ner- vous system, but may result from local nerve- disease. In cases of hemiplegia from cerebral mischief, the muscles of the thorax on the affected side are often temporarily weakened, but they usually subsequently regain • their power. When the upper part of the spinal cord is injured or diseased at a certain point, all the muscles of the chest become paralysed, which is a Tery serious matter,' as respiration and the acts connected therewith cannot be carried on, except by the diaphragm, and consequently the blood is imperfectly aerated, secretions accu- mulate in the lungs, and the patient dies from suffocation, c. Atrophy or degeneration msiy involve the thoracic muscles, jk cases of pul monary phthisis either the whole of these muscles or certain of them are not uncommonly wasted out of proportion to the general emacia- tion. These muscles may also be more or lesS' implicated in progressive muscular atrophy, and occasionally a single muscle undergoei marked wasting. The writer has seen a striking example of this local atrophy in connection with the peotoralis major, but the serratus magnus or other muscles may be implicated; The wasting is probably in most cases due to disease of the nerves supplying the affected muscles. It is 4uite evident on examination, and the movements which are usually performed by the involved structures cannot be executed properly, d. On the other hand, the chest-muscles may become hypertrophied. This may be a natural result of training ; or it may occur in consequence of their being called upon, either habitually or at intervals, to act excessively, as in cases of emphysema or asthma. In exceptional in- stances the condition known as pseudo-hyper- trophic muscular paralysis has extended' up to the chest, e. The thoracic muscles occasionally present marked irritability under percussion or friction. This has been regarded' as an! impor- tant sign of phthisis; but the writer has only observed it in a comparatively few instances of this disease, and has found it equallyif not more evident in cases where the lungs were perfectly healthy. /. As the result of injury and other causes, some portion of the muscular structiu'es of the chest may be lacerated, ruptured, or per- forated, either alone or. along with other struc- tures. This condition will be further alluded to presently. 3. Kervoua Affections. — a. Neuralgia is very common in different parts of the chest, especially iu the side, and particularly the lefl; side — intereostai neuralgia. The pain is' loca- lised, being usually referred to a point where a branch of nerve becomes superficial. It is more or less constant, but subject to exacerbations, in some cases being very severe at times. It may be increased by deep breathing or coughing, but is not, as a rule, bo much affected by these and similar actions as are other painful chest-iSk- tions. Shooting and darting sensations often riixliate from the principal point, and certain spots of tenderness — pointa douiowetai — raxj be recognised iu many cases {see IntbbC08UI OHEST-WALLS. MORBID CONDITIONS OF. Nbuealgu.). b. Intercostal neuritis is occasion- ally met with, and this affection is attended with great pain, localised and radiating, with much tenderness, the suffering being aggravated by whatever causes any local disturbance. It is probable that the severe pains experienced in some instances where the complaint is sup- posed to be muscular, are due to branches of nerve being in an inflammatory condition, c. Sume individuals, especially females, exhibit a remarkable superficial tenderness over the thorax or in parts of this region, especially the anterior and upper portions. The slightest touch is resented, and the most delicate percus- sion cannot be borne. This condition may exist without any actual disease, or it is sometimes observed in phthisical cases, d. Sensation may be more or less impaired over the chest, or in limited portions, either in connexion with central or local nervous disease, or in hysterical and nervous persons. Various parsesthesise are also frequently referred to this region by the class of indi\'iduals,just mentioned. 4. Diseases of the Bones or Cartilages. — The morbid conditions which may be referred to the bony and cartilaginous framework of the thorax are as follows : — a. There may be undue rigidity and firmness of the chest-walls, owing to an excessive deposit of calcareous matter in the sternum and ribs, with ossification or petri- faction of the cartilages. This is a normal con- dition in old people, being one of the degenera- tive changes to which they are liable, but it may also occur in younger individuals, as the result of hard work, or in connexion with certain pulmonary diseases. This state of rigidity interferes more or less with the respiratory movements, and not infrequently causes serious embarrassment. 4. On the other hand, the ribs and cartilages may be deficient in firmness, and consequently too yielding ' and elastic. This is observed in children and young persons who are ill-nourished, and it becomes a condition of great moment when any disease sets in which causes obstruction to the entrance of air into the lungs, such as bronchitis. The chBst-walls are then liable to fall in more or less during the act of inspiration, and may become perinahently deformed, the pigeon-breast and other abnormal forms of thorax being thus originated. In rickety children the vioiuity of the junction of the ribs with their cartilages is the most yield- ing part of the chest, where nodular thickenings may often be felt, and in such subjects this is the portion of the thoracib wall which is most liable to fall in. c. Acute or chronic periostitis or perichondritis is sometimes observed in con- nexion, respectively, with the sternum or ribs, or with the cartilages. The acute affection gives rise to much pain and tenderness, which may be accompanied with superficial redness and swelling, and may simulate some more serious disease. The chtonic complaint usually assumes the form of a node, being the result of syphilis. The writer has occasionally observed a small swelling at the junction of one of the ribs with its cartilage, painless, unaccompanied with red- ness, but presenting distinct fluctuation, d. The bony and cartilaginous structures them- colves may be the seat of disease in some part Of 238 the chest, and here must bs included the portion of the spinal column which limits this region posteriorly. Thus theire may be acute inflam- mation, caries, necrosis, or so-called scrofulous disease. Among the more important causes which are liable to originate these conditions may be mentioned injury, syphilis, scrofula, empyaema opening externally, and thoracic tu- mours or aneurisms growing outwards. Thsy may lead to serious consequences, both local and general, and frequently cause more or less deformity of the chest, e. Permanent thicken- ing and distortion of portions of the ribs are sometimes observed after fi:actures which have united improperly. 5. Inflammation and Abscess. — It is ex- pedient to make a separate group of those cases in which inflammation, resulting in the formation of one or more abscesses, occurs in some portion of the soft structures entering into the construc- tion of the chest-walls. This may be of local origin, arising from injury, bone-disease, or other causes ; or it may be due to the opening of an empysema into the tissues ; to suppuration ex- tending and burrowing from the axilla or other parts ; or to pyaemia. If d'eep-seated, an abscess may be difficult to detect with certainty, but usually the signs of this condition become sufSciently obvious. Sinuses or fistulae may be left as a consequence of suppuration in the chest-wall, especially when pus makes its way outwards from within. 6. Tumours and irew-QTO-wths. — These morbid conditions also demand separate notice. They may be connected with any of the struc- tures of the chest-walls, and are of various kinds ; among those which have come under the writer's notice may be mentioned molluscum, fatty growths, cystic tumours, enlarged sebaceous glands, and infiltrated carcinoma. Tumours may make their way inwards from the chest-walls, encroaching upon the cavity of the thorax ; or, on the other hand, the walls may be involved by growths from within. It need scarcely be mentioned that mammary tumours constitute a distinct, and by far the most important group associated with the structures covering the chest. See Brkast, Diseases of. 7. Perforations and Buptnres. — The mus- cular structures of the thoracic wall may be more or less destroyed in some part either by sudden rupture or gradually, allowing a hernial protrusion of the lung to take place between the ribs. As already noticed, empyaema may make its way'outwards through the chest-wall. Aneu- risms and tumours extending outwards from within the thorax frequently cause serious de- struction of the tissues, including the bony and cartilaginous, as well as the soft structures. This destructive process is often attended with severe pain and suffering, and leads to grave mischief. 8. Variations in Form and Size. — The chest often presents deviations from the normal shape and size, and these are so important that they demand separate consideration. See De- FOnMITIES OF ChBST. Tkeatment. — In many cases where the chest walls are in a morbid state, they either do' not need any special treatment, or ho treatment can 231 CHEST-WALLS, be of avail. The chief circumstances under which the practitioner may be called upon to interfere, and the measures to be adopted, may be briefly indicated as follows : — a. Painful affections of the chest-walls, de- pending upon conditions of the muscles or nerves, frequently demand local applications for their relief. Thus in diiferent eases it may be requisite to employ hot fomentations, di^ heat, or cold applications, in the form of wet rags frequently changed, ice, -or eyaporating lo- tions ; or to use anodyne applications of various kinds, such as belladonna . plaster or liniment, opium plaster or a liniment containing laudanum, oleate of morphia, tincture of aconite or ointment of aconitine, or veratria, ointment. Anodynes may also sometimes be added to fomentations with advantage. Priction is often of much ser- vice, and at the same time stimulating liniments may be employed, such as one containing cam- phor, chloroform, or turpentine. For ill-defined muscular pains about the chest, which are fre- quently complained of, free douching with cold water every morning, followed by friction with a rough towel, is often highly ef&cacious. When pain is localised and obstinate, much benefit may be derived from the application of a sinapism, mustard-leaf, or even a small blister. In other cases the use of the ether-spray is serviceable, repeated more or less frequently; or sometimes much relief may be obtained from applying over a painful spot a mixture of equal parts of chloro- form and belladonna liniment. Galvanism, is another agent which may be of the greatest ser- vice in relieving painful sensations about the chest, whether connected with the muscles or nerves. Subcutaneous injections of hot water, morphia, or atropine may be demanded in some cases, anl constitute a most valuable mode of treatment if pain cannot otherwise be assuaged. In the treatment of many painful affections of the chest-walls much assistanse may be derived from attention to posture, especially in connec- tion with certain occupations; from the avoidance of undue fatigue, or of any violent actions which are known to influence this part, such as cough ; and from the adoption of measures tending to support the structures, or to keep them in a state of rest. The writer has found great benefit in a large number of instances from strapping the side more or less extensively, in the manner advocated by him for the treatment of pleurisy ; and if there is any localised pain, some limited anodyne application, such as a piece of belladonna plaster, may be placed over this spot under the strapping. b. In many affections of the chest-walls, treat- ment directed to the general system, or to some special constitutional condition, is often of the greatest service. Thus, in the painful complaints already noticed, there are frequently marked gene- ral debility and anaemia ; and essential benefit is derived from the administration of quinine, pre- parations of iron, strychnine, cod-liver oil, pre- parations of phosphorus, and other tonic medi- cines, or such as improve nutrition. Some of these are also most useful when there is disease of bone and its consequences. Again, certain af- fections of the thoracic wall may be associated wiih rheumatism, gout, ar syphilis, and then the CHICKEN-POX. particular treatment indicated for each of these several conditions is called for. c. When disorders of the muscles of the chest- walls occur, such as paralysis or spasm, asso- ciated with some disease of the central nervous system, the treatment must usually be directed to this disease, and but little can be done for the local disturbance. In some instances, however, electrical or other modes of treatment may be of some service, by infliuencing the action of the muscles, but no definite rules can beilaid down. d. Local inflammations in connectiion ^th the thoracic walls must be treated as in other parts of the body, and it is unnecessary to discuss this subject in the present article. e. Surgical treatment may be called for under certain circumstances. Of course this will be ths case if the chest-walla are injured in any way, Among other conditions likely to demand sur- gical interference may be specially, mentioned subcutaneous emphysema, abscesses, diseassi of the bones, and tumours. Pbederick T. Eobbrts. CHE3T-"WAIjIiS, Deforniities of. See Sefobuitiss of Ou£st. CHIOKEN-POX.— SiNON. : Varicella ;ir, La Varicelle; Ger. Wasserpoc&en, Definition. — A specific infectious febrile disease, characterised by the appearance, in sue* cessive crops, of red spots, which in the course of about a week pass through the stages of pimple, vesicle, and scab. .aixiOLOGT. — The origin of this disorder is un- known. It is certain that it, arises from con- tagion, and that childhood is its predisposing cause. It occurs in children at the breast, and is seen with increased frequency up»to the fourth year, at which period it attains its maximum. It is less often found between fogr and twelve, and after twelve it may be said to disappear, although it is occasionally seen in adults. SoiPTOMS. — The illness commences without any, or with but slightly-marked premonitories. There is usually, however, some feeling pf lassi- tude, and the patient goes to bed earlier than usual. Within a few hours an eruption appeals, usually on some part of the back or chest, but there are many exceptions to this rule. It may commence on the face, neck, chest, abdomen, or extremities, or upon several of these parts at the same time. The eruption consists of small, faintly papular rose-spots, varying in number from twenty to one or two hundred. These, in the course of eight, twelve, or, at the most, twenty- four hours from their appearance, change into vesicles, which, at first small in size and clear as to their contents, become quickly large ; globular, ,or semi-ovoid in form ; translucent, glistening, and opalescent in appearance ; and surrounded with a faint areola. Towari the end of the second day of illness, the vesicles attain complete development, and about this time a few may be seen on the sides of the tongue, on the lips, cheeks, or palate, and sometimes upon the raucous membrane of the genitals. About the thirdday a few of the vesicles may have a pustular appear- ance, and sometimes a few pustules are seen ; hut, regarding the eruption as a whole, pustulation forms an incident lather than an essential feature OHICKEN-POX. in it« progress. On the fourth day the vesicles begin to dry up, and by the sixth complete scabs are formed. These fall off in a few days, leaving in their place faintly red spots, and sometimes nfew pits. A single crop of the eruption may be said to complete itself in five or six days ; and, as two or three crops appear on as many Buecessive days, the illness will last rather more than a week. In the event, however, of there being four or five crops, it may be pro- longed for another week, but this is unusual. With the appearance of the eruption, the tem- perature rises two, three, or even more degrees, and this rise recurs with each successive crop of spots. The pulse is sometimes slightly increased in frequency ; the tongue is moist, and sometimes covered with a light fur. As a rule, however, there is but little constitutional disturbance, although it is occasionally severe. Pathology.— Chioken-pos is due to the re- ception of a specific poison, which after an incu.i bation of about thirteen days, shows itself by an eruption upon the skin. What this poison is, how it enters the body, and what, if any, changes it produces upon the internal organs, the present state of oiir knowledge does not enable us to say. It affects the siime individual once only, and it is perfectly distinct from modified small- pox, as the following considerations will show: — 1. Chicken-pox is characterised by the rapidity with which it runs through its stages ; modified small-pox, on the contrary, ii characterised by an interruption in-the course of the disease at one or other of three points — the papular, the vesicular, or the pustular. 2. The chicken-pox eruption attains complete development by the end of the third day; in modified small-pox, should the eruption attain complete develop- ment, this will not occur before the ninth day, however much the disease may be modified. 3. In modified small-poX the premonitory symptoms are usually well-marked, often quite as severe as in the natural disease, and these last forty-eight hours, after which there is an eruption of small hard papules on tbe forehead, face and wrists, fol- lowed by afall of temperature. In chicken-pox the premonitories are most often wanting, and when present are slightly marked, and the erup- tion is followed by a me in the temperature. It appears, moreover, upon any part of the body in- discriminately, and less frequently on the &ce than on other parts; and within a few hours — atthe most withiji twenty-four — ithasbeoome.vesieular; whereas in modified small-pox the vesicular btajie is only reached forty-eight hours after the appear- ance of eruption. 4. The vesicles of chicken-pox are globular or ovoid in form, without any central depression; glistening or translucent in appear- ance ; and unicellular in structure. They collapse on pricking, and attain their maximum develop- ment in from twelve to eighteen hours. Modified and natural small-pox vesicles are fiat and circu- lar in form, always depressed in the centre, and sometimes umbilicated, of an opaque dirty white colour, and multicellular in structure. They do not collapse on pricking, and attain their maximum development at the end of the third day from their origin.' S. Small-pox is an inoculable affection ; chicken-pox, according to reliable authority, is not. 6, When cases arise CHIGOE. 28S whioli all recognise to be modified smoll-pox, they are always accompanied by others which are more severe ; and in epidemics these latter gradually become more numerous up to a point of maximum intensity, when they deolme and the modified forms reappear. .In ohioken-pox there is no suoh gradual increase in the intensity of illness, and neither serious nor fatal oases form part of its epidemics, which prevail indepen- dently of gmall-pox. 7. Small-pqx and vaccinia are often early followed, in the same individual, say within two or three years, by chicken-pox, and vice versa. 8. Chicken-pox, vaccinia, and small-pox have been known to follow in imme- diate succession in the same individual. GoiiESE, TBRMiNATioNa, Seqiieub.^ — Varicellii always runs a favourable course, invariably ter- minates in recoveiy, and has no sequeUe. DiAONOSis.— It should be borne in mind that a sure diagnosis cannot be made in less than forty- eight hours. The appearance, however, of a crop of vesicles, followed on the next day by a second crop, points almost certainly to chicken-pox. Attention to this, and to the points noted un^er the head of pathology, ought to make the diagnosis easy. Pboqnosis. — This, as has been indicated above, is always favourable. Tbeatmbnt. — ^The treatment of chicken-pox consists in confining the patient to his room, or in, the more marked cases to his bed, for one or two days; and in the administration of light, unstimulating food. Although no physician has recorded a fatal case of chicken-pox, a child whose temperature may be three, four, or six degrees above the normal, should be watched with care. Alex. Collie. CHIGOE. — Desobiption. — The Chigoe is a minute parasitic insect, common in the West Indies and northern parts of South America. It is also popularly known as ike Jigger ov Sandflea. Though formerly regarded as an acanis or mite, it is now generally recognised as a true fiea be- longing to the genus Pulex (P. penetrans); but several entomologists have advanced solid reasons for separating it from the ordinary fleas. Thus Weetwood terms it the flesh-flea, or Sarcopsylla penetrans, whilst Gu^rin formed the genus Vermatophihis for its reception. Practically, these distinctions are of little moment. The Chigoe ordinarily lives in dry and sandy situations, where it multiplies to a prodigious extent. It attacks, however, the feet, chiefly underneath the nails and between the toes ; the impregnated females burying themselves beneath the skin. Here the abdomen of the parasite swells to the size of a pea; and, unless removed by operation, qives rise to acute local inflamma- tion, terminating in suppuration and son;etimes in extensive ulceration, with even fatal results to the patient. Dogs also suffer excruciating torment from the bites and immigration of the Bicho do Cachorro, which, however Pohl and Kollar regard as distinct from the human jigger (Bicho depe)..'Be that view correct or not, it would appear from the observ?itions of Rodschild and Weatwood that the larvsp of the humiin chigoe are liatched inthe open wounds or ulcers, which some- times extend inwards so as to involve the bones 236 CHIGOE, themselves. In bad eases amputation of the toes and adjacent parts becomes necessary. Left to themselves, the larvae escape from their host, and probably, after the manner of bots and other parasitic insects, penetrate the soil for the pur- pose of acqniring the pupal stage of growth. Thbatment. — As regards treatment, the in- dications are simple. The parasite should be removed with the utmost care. Where this has not been done, and where, as a conse- quence, open sores exist, frequent washings with tepid -water, followed by the application of car- bolic acid lotions (twenty or thirty grains to the ounce), or of ointmeilts (one drachm to one ounce of benzoated lard) will be found most suitable. Or, again, the carbolic acid putty, as sold jn shops, or the application of one part of the acid previously m'xed with ten or twelve parts of simple olive oil, will, in all likelihood, bo suffi- cient to cause the destruction of any larvae that might remain. In European practice cases of jigger are rarely seen; nevertheless the Writer has recorded an instance in which strong men- tal delusions followed the torture produced by these creatures (Worms, p. 141). The pa- tient, a middle-aged married lady, had suffered severeljj during her residence in the West Indies. Although she had got rid of the parasites, she constantly harpooned her own feet in the hope of destroying the young jiggers which she felt sure were still burrowing beneath the' skin. Lastly, it seems almdst needless to say that residents and travellers in Guiana, Brazil, and in the West Indies generally, should haTO their feet properly protected. T. S. Coebold. OHILBL AIN.— Stnoh. : Ebe ; Pernio ; Fr. Engelure ; Ger. Frostbeule. Definition. — A state of inflamma/tion of a part of the skin induced by cold. .Etiology. — Chilblains are common in children and young persons, and are more frequent in girls than in boys. They occur chiefly in those of a lymphatic constitution, and may be considered as an indication of debility and deficient vital power. In adult age they are rare, and are only met with when the powers of the constitution are reduced. Their occurrence is influenced more by the strength of the individual than by the degree of cold, and th ey continue in some persons throughout the entire year. Their tendency is to etase with the full development of the organism, and they reappear occasionally in aidvanoed life; Description. - The regions Of tlie body usually affected with chilblain are the feet and hands, to which are sometimes added the ears and nose. A chilblain presents three stages or degrees of severity, namely, erythemuious, btiUous, and gan- grenous ; and it may be arrested at the first or second stage by the withdrawal of the cause. The erythebiatous stage is restricted to hypersemia, swelling, and severe burning and itching, the itching being increased by heat, as by that of the fire or that-induced by eiercise. The congested spot is circular in figure, some-what' tumid, brightly red at first, but later on roseate crimson, purple, or livid in colour. The second or bulUma stage exhibits the blain or blister re- sulting from effusion of serun beneath the otlticle; the permanent colour of the' swelling is CHLOEOSIS. now purple or livid, and the contents of the blister a limpid serum, generally -reddened -vrith blood ; sometimes, indeed, the fluid- of the blister may be semi-purulent. In the gangrenous stage the blister is broken, the surface of the derma is in a state of gangrene, and the gangrenous layer is subsequently removed as a slough ; by ulceration. ' - Treatment. — The treatmeiit of chilblain re- quires to be modified to suit its different degrees. In the first, the indication ■ is to restore normal circulation by gentle friction, and, when the part is severely chilled, it is usuhI to rub it with enow; then some soothing liniment maybe employed ; and, finally, a stimulating liniment, covering the part afterwards -with zinc ointment shd cotton wool, or shielding it with lead or opium plaster spread on washleather. The-hni- ments most in ■ favour for this purpose are the soap liniment vrith chloroform, the compound camphor liniment, the turpentine liniment, and the linimentum iodi. In the bullous stage a similar treatment nay be used to the erythema- tous portions, whilst the blister should be snipped and the broken surface pencilled with the compound tincture of benzoin, and afterwards dressed With uuguentum resinae or an ointment of Peruvian balsam. In' the third stage the erythematous phenomena still require attentions and the ulcer shoidd be dressed with unguentum resinae, either alone, or in combination -vrith spirits of turpentine. • i To ob-viate constitutional "debility, the diet should be nutritious and generous, and recourse may be had to tonic remedies, ;Suoh as iron and quinine. Euasjids Wilson. CHILIi. — A subjective sensation of coldj ness, accompaiiied with shivering, and most frequently experienced in connexion -with febrile or inflammatory diseases, in nervoiis individual'4 and after exposure to cold and wet. In popular language ' taking a chiU ' is used as synonymous with ' catching a cold.' See Eigoe. OHIIT-OOIJQH. — A synonym for whoojiBg- cough. &e Whooplnq Cough. ,: -, CHIKAGEA (xflp, the hand, and iiypa, a seizure). — Gout in the haiid. See Govi. ' CHLOASMA (x^administration of brandy have in the writer's judgment appeared to do much good. It is in these cases that tartar emetic in full doses has been recommended ; it is certainly tolerated in an astonishing degree. Kestraint of the violent movements is often a great comfort to the patient ; the limbs should be carefully bandaged with flannel and bound, the legs together, the arms to the sides, a folded blanket, across the abdomen and hips, keeping down the body. If half-done it, only adds to the suffering, but when properly carried out it gives a feeling of relief and favours W. H. Bboadsent. CHYLUEIA. 249 OHOEOIDITI3. — Inflammation of the choroid. See Eye, Diseases of. CHBOMIDKOSIS (xwo, colour, and Bpws, sweat), coloured perspiration. See Peespiea- TioN, Disorders of. CHEOITIO {xpivos, time).— This word is applied to a disease when its progress is slow and its duration prolonged. See Disease, Dura- tion of. OHTLOTTS VBXSTE.—See CHYLUEii. OHTL0EI A (x"^!>s. chyle ; and oloov, nrine). — Synon.: Galacturia; Chylous urine; Fr. Urine laiteuse; Ger. Die Chylurie; milchsaf- tiger Hamabgang. Definition. — A diseased condition, occurring in tropical and sub-tropical climates, which manifests itself by a milky appearance of the urine, accompanied usually with more or less distinct traces of blood. On standing, the fluid coagulates, so as to present the appearance of size. A microscopic nematoid entozoon {Filaria sanguinis hominis) is generally found in the blood and urine of persons affected with the disease. Geneeal Desoeiption. — The affection known as chylous or chyloid urine has long remained a puzzle to physicians, not only on account of the very remarkable character assumed by the secretion, but also on account of the very erratic course which the disease runs. Scarcely any two persons affected with this malady give a similar account of its mode of onset, of the duration of the attack, or of the symptoms and seasons of its occurrence. The writer has had the opportunity of studying from thirty to forty cases of the disease in. Calcutta, and the variety of symptoms presented, and the numerous causes, of the most opposite character, to which the disease has been attributed, are very perplexing. The histories of the cases published by various observers present a like uncertainty, and Dr. "William Eoberts very aptly describes the course which the disease runs as marked by an irregu- larity and capriciousness which ba£9es explana- tion. It woiJd seem as though the one symptom which may be looked upon as constant is the condition of the urine implied by the designation which was applied to the disorder by Prout. This symptom, however, although very ap- plicable to the generality of cases met with in India, does not appear to be so generally ap^- plicable to the disease as it occurs in Egypt, the Brazils, and the West Indies. In these countries the term kcsmaturia is adopted as being a more correct description of the malady, whereas in India the designation ' hsematuria,' though gene- rally more or less applicable at some period or other of the disease, is, nevertheless, not so ap- propriate in the great majority of the cases, and, indeed, in some instances is wholly inappropriate, as occasionally no marked traces of red colouring matter can be detected in the urine from the beginning to the close of the attack. It is, of importance that this feature in connection with the disease should be borne in mind, as it may hereafter be found that what at present are gene- rally considered as merely two phases of one malady may each have a distinctive aetiology. HisTOEY AKD Geogeaphioal Disteibction. — The phase which chyluria usually presents in India is, in this article, taken as the typical one, and its history may be thus briefly epitomised. To Dr. Vandyke Carter belongs the credit of having observed systematically, and seriously attempted to clear up the pathology of the disease. His researches, published in 1861-62 tended to show that a direct admixture of chyle and urine occurred — a leak from the lymphatic tract into the urinary.' In March 1870, when * Transactions Med. and Phya, Soc, Bombajf, vol, vU. 1861. Medko-chir. Tram., vol. xlv., IMS. 250 CHYLUEIA. examining a Bpecimen of milky urine passed by a man nnder the charge of Dr. E. T. Lyons in Calcutta, tne -wrifjer found that it contained numerous microscopic nematoid worms in a living condition. These were described and figured in a report published in 1870 by the Indian Govern- ment.' Under the impression ! that no nematoid parasites had previously been found in the urine, specimens were forwarded to the late Dr. Parkes, and by him shown to Professor Busk, who sug- gested that probably they belonged to the Filari- dae. Similar entozoa were detected in the urine of, chyluria patients in Calcutta by Dr. W. J. Palmer and Dr. Charles in the course of the next few months. Towards the beginning of July 1872 the writer found nine minute nematoid worms in a state of great activity on a slide containing a drop of blood from the finger of a Hindoo. These were identical in character with those above re- ferred to. Unfortunately the man could not be found after the observation had been made, so as to be questioned as to his past history, so that the pathological conditions which might have been associated with this the first recorded instance of the existence of nematoid hflematozoa in man must continue to remain in obscurity. However, since this period the writer has traced the helminth, (named Filaria sanguinis hominis) to the blood direct in about fifteen, and to one or other of the various tissues and secretions of the body in about thirty-five individuals. All with the ex- ception of the person just referred to were known to suffer or to have suffered from chyluria or some closely allied pathological condition.^ These observations have, moreover, been confirmed by others in numerous instances. ^ The more recent history of the variety, of the disease usually referred to as ' h^maturie grais- seuse,' 'hsematuria Braziliensis,' 'haematuria Egyptica,' is also associated with an entozoon — or rather with two distinct kinds of entozoa — a fluke and a nematode. Tka former was dis- ' covered in 1851 by Bilharz. His observation was followed up, and now it is estimated that about a third of the inhabitants of Brazil harbour this parasite in their bodies. In 1868 Dr. Otto Wucherer, of Bahia, discovered a microscopic entozoon, which he forwarded to ' Leuckart to be identified.^ The latter writer' suggested that it might be the embryo of some round worm, probably belonging to the strongy- lidffi. Dr. Jules Crevaux, a French naval surgeon, succeeded in confirming Wucherer's observation by finding (July 27, 1870) similar helminths in the urine of a young Creole afieoted with ' hema- turie chyleuse.'* The next link in the chain appears to have been furnished by Dr. Sonsino, who.in January 1874 (having no knowledge of previous: observations of alike character), found similar parasites in the blood and in the urine of ' Vide abstract of this description in BriUih Jtedical Journal, Nov. 19, 1870. " On a Hsematozoon in human blood ; its oonnectloii with Chyluria and other diseases.' Vide Eighth Ann. Rep. ofSmttary Commisi. with Govt, of India, 1872 : aiso Indian Ann. Med. Science, vol. xvi. ' On the Pathological Signifloanoe of Nematode Hiema- tozoB.'. Tenllt Seport of Sanitary Comimii., 1874 : also Indian Ann. Ued. Science, vol xvil. ■ Gaiilla da Bahia, Deo. 1868. * Joum. de I'Anat. et de la Physiol. T. xi., 1875 • and Leuckart'a ' Parasitm,' Band ii. S. 628 et seq. a Jew lad at Cairo affected with hatmatnria, In the latter fluid distomata also were found. This observer, however, considers thalt these parasites, though beaa-ing a very close resem- blance, differ in some respects from those found in chyluria, and has accordingly added the word Egyptica to the original designation for tb purpose of distinguishing it. ' It- is possible that the microscopic nematode which "vras dis- covered by "Wucherer in Bahia may also he traced to the blood eventually, and that th? slight differences in the recorded characters in the worm as found in Egypt and in the Brazils from that found in India may be shown to bs sufficient to indicate a specific difference io the parasites, and thus offer a satisfactory explanation of the discrepancies observed i-j the character of the urinary disorder In the different countries. In Europe the disease has been investigated by several observers. The cases which have come ander their care have occurred with very rare exceptions in persons who have at some time or other resided in countries situated between abont 30° north and 30° south latitude. Of the four or five cases which have been recorded as having originally occurred in Europe, one is furnished by Dr. William Eobeits, the patient never hav- ing been out of Lancasliire ; and another by Dr. Beale, in a person who had never resided out of Norfolk.' Symptoms. — So far as is at present known, there are no premonitory symptoms of chyluria. Sometimes the only symptom is the milky condition of the urine — a condition which usually comes on very suddenly; generally, however, the patient complains of uneasiness, scarcely amounting to pain, across the loins, along the ureters, over the bladder, or along the course of the urethra — especially towards the perinseum in the male. There is gener- ally marked debility, with mental depression. Occasionally chylo-serons discharges take place from various parts of the body — the axilla, the surface of the abdomen, the groin, and especially from the scrotumi in that con- dition of it which is known as Elephan- tiasis lymphahgiectodes (Bristowe), Nsevoid elephantiasis, or Varix lymphaticus. The disease is also sometimes observed associ- ated with true elephantiasis of the limbt and scrotum. It occurs at all ages, from childhood to extreme old age, and in about equal proportion among the sexes— perhaps more freqiiently in the female than in ths male. With regard to ths urine, it present*; as alread) mentioned, a milky appearance, and frequent^ emits a strongmilkyor whey-like odour, which is made more evident by warmth. After standing a short time the fluid coagulates, so as to form a more or less semi-solid ma^ resembling blanii- mange. In the course of a few hours the dot breaks down, and the urine becomes rapidly de- ' Dr. S. Mackenzie exhibited to the Pathological Society (October 1881) living speoimenB dtfllaria from a soldier who had served in India. Henotidedthedailylierioaicity of the Glaria, which had previously been determined by Dr. MansoQ of Amoy, and further showed thatitbe perio- dicity could be inverted from day to night by changinK the habits of the individual. CHYLUEIA. 251 camposed. In some cases the fluid presents a pink colonr, from the admixture of blood, but more commonly — at least, in India — the blood, ■when present, is seen forming a shreddy adhe- rent coagulum at the bottom of the Tessel. Not unfreqnently the flow of urine is, suddenly stopped during micturition by the blocking up temporarily of the urethra with one of the clots. Sometimes in India, but apparently almost al- ■ways in the West Indies, South America, and Egypt, the presence of blood in the urine forms, as already mentioned, the most pronounced fea- ture. The specific gravity varies greatly — may range in the same individual from. 1007 to over 1020. Shaken up with ether the urine loses its milky aspect ; and when nitric acid or heat is applied a precipitate almost invariably results. These characters, and the fact of the coagu- lability of the fluid, indicate the presence of fiit, albumen, and fibrin, all of which are to be con- sidered as abnormal constituents. The propor- tion, however, in which they exist in different individuals, and even in the same individual at different times, varies greatly. Dr. Beale's analyses show, that though a specimen of urine may contain at one time 1"39 per cent, of fat, another specimen, obtained a few hours later, from the same person, may contain none. In the majority of cases the fatty element is usually scanty in the morning before meals, and so are the other abnormal elements, unless exercise have been taken or the circulation otherwise accelerated. Under the latter circumstance, as Dr. Sence-Jones has shown, the albumen is increased, without, however, a corresponding increase of the fat.' It is evident, therefore, that in order to institute a comparison between the character of the urine and the character of the various nutritive fluids for the purpose of ascer- taining from which of them the abnormal con- stituents of the urine are derived, the results of analyses of the latter fluids at different times of the day and at difierent stages of the disease should be taken. Further, as the nutritive fluids themselves undergo constant changes de- pendent on the quality of the nourishment sup- plied and the time which has elapsed since par- taking of it, it is equally evident that any single analysis would be insufficient. An attempt has been made to bring together in the following table all of what appeared to be the most trust- worthy analyses of these fluids which have been published. In order to simplify the table, only the estimates of the albuminoid and fatty matters have been given, these being the most pronounced of the more readily estimated abnormal con- stituents in the urine : — Constituents selected. 1 j UniHB in chy- .luria. [Mean of 15 an- alyses]. BLOon in chy- Jnria. :Hpppe- Seyler.] BLOon — Nor- mal human. [Beo- qnerel and Rodier.] Chyle [Mean of 6 an- alyses : man, cow, horse, »ES,d0g, cat. Ltmph —human [Mean of 4 an- alyses]. iAIbuminoida Patty . mat- ters. 0-54% O.SO% 3-35% 0'67% 7-00% 006% 7-08% 0-82% s-se% 0-56% ' Phil. Train, of Royal Sue., cxl., 18S0, p. 6S1. A glance at this table reveals the fact that tho relative proportion , of the albuminoids to the fatty matters in chylous urine does not corre- spond with the proportion in which they are found in any one of the nutritive fluids of the body. In normal blood, for example, the fatty matter is as 1 to 1 16 of the albuminoid, whereas in the urine the former exceeds the latter to a very considerable extent. The same discre- pancy, but to a less degree, is found to exist when the urine and chyle are compared — the quantity of albumen in the latter being more Hian seven times greater than that of fat. The proportion of these substances in lymph ap- proaches more closely to what is encountered in the urine — the fat being to the albumen as 1 to 4 very nearly. The specimen of ohyluria-blood recently analysed by Hoppe-Seyler' apprftaohes very closely to the average composition of human lymph — the fatty matters being as 1 to 5 of the albuminoid, thus differing in this respeet very considerably from Dr. Bence-Jones' analyses of similar blood where the quantity of fat given is that of normal blood. On the other hand, the urine of the man from whom this blood was ob- tained yielded a proportion of fat almost iden- tical with what Hoppe-Seyler obtained in the urine of the person whose blood he examined — the figures given by the former writer being O-7'l and by the latter 0'72 per cent. The composi- tion of the blood in this affection must be re- garded as hitherto unsettled. Guibort found in a clot of it almost twice, and Hoppe-Seyler about eleven times as much fat as is found in normal blood ; on the other hand, Eayer, Bence- Jpnes, and Creyaux could detect no change in its composition. It is possible that the discre- pancy in the results of these analyses and macro- scopic examinations of the blood may be due in part to the particular moment when the blood was abstracted. According to IVt. Claude Ber- nard, ' Les urines chyleuses resemblent au sang d'un animal en digestion, ou plutot a celui des oies que I'engraisse.' ^ With regard to the mieroscopic examination of the blood, the writer has not observed that the corpuscles or serum presented any abnormality indicative of the presence of fatty matter in any form—the serum has seemed as clear and as free from molecular matter as normal blood. So far as his experience goes, the only feature worthy of special note in connection with microscopical examination of the blood in chyluria, is, the pre- sence of the hsematozoon already referred to. In searching for it, it will be advisable to abstract by means of a needle a drop of blood from several fingers, and to submit each slide to a thorough examination, which may have to be very pro- longed, employing for this purpose a compara- tively low power — f" or i" objective — a higher power being resorted to vmen the entozoon has been detected. It must not be expected that the blood will present any peculiarity to the naked eye, even tlough every otmce may contain thou- sands of these microscopic worms. The accom- ' Mei.-ehem. Untersuchutiffen, 1871, s. 651-66. Abstract by Dr. FeiTier in Joum. Chem, Soe., vol. ix., 1871 j pogo ' Quoted by Cievaux, , eti. 2S2 CHYLUEIA. panying -wfood-cut, traced from a micro-photO' graph, accurately represents the size and form of the parasite. Its average length is i"( = 0-34mm.); its breadth _JL_'> ( = 0-oe7mm.), or about equal to the diameter of a red blood-corpuscle. It is enclosed in a transparent tubular sac, within ■which it can be seen to alternately contract and elon- gate itself. This sac is extremely delicate and translucent, and may sometimes, ■when the worm has shortened itself more than usual, be seen collapsed and folded like a ribbon, and the next moment be instantaneously straightened again, by the extension of the filaria to its ordinary length. After death the ■worm may occupy either the entire length of the tubular sac, or be so contracted as to leave the tube empty at one or both ends, as may be observed in the ■wood-cut.' The internal organs are not sufficiently differ- FiG. 11. entiated to be recognised with Klaria Sanguinia anything like certainty, although Eominis. ■when carefully scrutinised from (Traoed'from a *™® ^ *™^ during the twenty- micro-photo- four or forty-eight hours that the graph.) parasites may continue to live, something like differentiation of an alimentary canal may be recognised. Mieroscopioal Cha/raciers of the Urine. — The filaria may likewise be detected in the urine. One day it may be readily obtained in the blood but not in the urine, and vice versd ; but, as a rule, the parasite will be found equally readily in both fluids. In making a search in tlio urine, it is ad^visable to pick out one of the coagulated shreds generally found in it, transfer it to the glass slide by means of a forceps or pipette, and carefully tease the fragment before applying the cover-glass. The other leading microscopical character of the urine is the minutely molecular matter — fat in an emulsified condition — to which the fluid owes its opaliiie or milky aspect. There are also numerous white, lymphoid corpuscles, together with red corpuscles, numerous or the reverse according to the degree of sanguinolence of the airine. Casts of the tubular structure of the kid- ney — indicativeof organic disease of these organs — are seldom to be seen ; they were absent in all the cases that have come under the writer's obser- vation. Anatomical Chaeactees. — The post-mortem examinations of persons who hare died whilst affected ■with chyluria, also testify to the free- dom of the kidneys from disease. This was the case in two autopsies conducted recently ' The microscopic ivorms detected by the writer (In Jnly 1874) m the blood of dogs in Indiar-presumably the same Bpecics as those discovered by MM. Grube and Delatond, in Prance, about 1843— are not enclosed in an envelope ot this kind, although In every other ■way they appear to be identical ; and Br. Sonsino states that the hsematoioon found in Egypt is also destitute of this cn- velopuig tube, as is likewise the urinary nsxosite dis- covered by ■Wncherer. by Dr. MeConueU in Calcutta. The ■writer had the opportunity of examining the kidneys of the first case, and of all the organs of thehody of the other case, but could find nothing in any of the organs or tissues suggestive of being a cause of the urinary derangement; except the fact that all the vessels — arteries as well as veim —contained the filaria in their minutest ramifica- tions. It may be further mentioned that the entozoon is present in the chylo-lymphous dis- charges which have already beeii referred to as sometimes accompanying chyluria. Of this tho writer was able to satisfy himself in 1872, anS repeatedly on subsequent occasions. In one of the instances the secretion flowed from theinnir corner of the eye, several ounces of whioh'escaped daily; the others were cases of elephantiasis lymphangiectodes, or naevoid elephantiasis of tho scrotum. For a summary of what is known of the latter affection, the reader is referred to a caref ully--written paper by Dr. Kenneth Mclebd.' .SItioloot and Pathology. — Haviig consid- ered in detail what seem to be the leading J}atho- logical features of chyluria, a brief refertoetaay be made to the views which at present pieVail regarding its setiology. These may be comprised under three heads: — (1) Dr. Vandyke Carter advocates the view that a direct communication exists between the chyle-carrying vessels and the urinary tracts. (2) MM. Claude Bernard and Ch. Robin believe that the conditioij of the urine is but a symptom of piarrhseraia— fatty blood ; the latter condition being but the normal condition of the blood for some time after the partaking of food, aggravated and made perma- nent by derangement of the digestive organs— notably the liver. One of these, distinguished authors (M. Eobin) suggests, further, that this derangement is probably induced in the liver and elsewhere by the filaria sanguinis hominis.' (3) The third view to be noticed is that advanced by Dr. W. Eoberts. This view appears to be hascd mainly on the history of a very remarkable case, published by him in 1868. It was one in which a eoagulable chylo-lymphous discharge escaped from open vesicles which had formed over the surface of the abdomen : the patient's mine ■was, moreover, chylous for two days. Dr. Eoberii suggests that a condition somewhat similar to that on the surface of the abdomen existed iil the urinary tract, — a sort of eczema— pipfahly on the front of the bladder. Post-mortejnjej- amination did not however confirm, this view, nor could anything be detected in any o|,,,th6 organs suggestive of a cause, but Dr. Eojjerts infers that this was probably due ' to the fact that in the last few weeks of life the mortid process had retrograded and had consequently left no appreciable marks on the surface of the bladder.' The examination of the skin in the diseased part showed that the cutis vera and the suboutaneoni tissue were traversed by short channels or lacunse from the ■width of a crow-quill to that of a hair. A careful study of this and other cases suggested to Dr. Eoberts the view that one, at least, of the forms of chyluria may be due to hypertrophy of the lymphaticchannels and snb- sequent acquisition by them, of gland properto, ' Indian Medical Gazette, August 1874. " • 'I*9onB BUT les humenrs' ; 2nd edit. 1874, p. 846. CHYIURIA. In the piesent state of our knowledge, how- ever, it cannot te said that any of these ingenious explanations meet all the olijections that might he raised, F07 example, hefore the e^iplanation suggested of the direct leakage of the chyle into the urine can he accepted as sufficient, it must be shown that such a leakage is anatomically pos- sible, and, secondly, that the relative proportion of the leading constituents of the two fluids agree more closely than is suggested by the greater number of the analyses hitherto published. M. Robin's view does not suggest any special anato- mical difficulty, but it remains to be demon- strated more conclusively than has hitherto been done that the blood in man ever contains a sufficient quantity of fatty matter to produce such extreme milMness by admixture with the urine as is observed in chyluria. Dr. Eoberts' theory is certainly not open to these particular objections, as, given a certain agent to start the formation of these glandular tissues, there does not appear to be any special anatomical or phy- siological difficulty to be got over; but the result of all the autopsies as yet recorded do not war- rant the inference of the existence of such patho- logical conditions. Future observation, however, may show that they really do exist. Of the setiological significance of the presence of the filaria in the circulation there can, the ivriter thinks, scarcely be much doubt — more especially when the number of observations re- corded within the short period that has elapsed since attention has been drawn to its existence therein, is taken into consideration. These sug- gest more than a fortuitous connection; indeed it might rather be said that chylo-serous effiisions may be considered as symptomatic of the para- sitism. Filariae have even been detected shortly Je/bre, chyluria had manifested itself. Whether they act iiyuriously by giving rise to rupture of the walls of the delicate channels in which they circulate and thus cause the escape of the dif- ferent nutritive fluids into the urinary tract ; or whether, as M. Eobin suggests, they produce de- rangements of the liver and other organs which give rise to piarrhsemia (and, probably M. Eobin would add, to rupture of the capillaries, so as to permit of the escape of the abnormally fatty blood), it would be premature to express a defi- nite opinion. It is possible that both Carter and Eobin may be correct to some extent, for the disease presents many phases; and the writer would suggest further, that it may also be possible that, in addition to giving rise to the escape of fluid in a purely mechanical manner by causing ruptures, local congestions, and so forth, the entozoon may in some way tend to the pro- duction of minute secreting structures (analogous to those described by Eoberts as having been formed in the subcutaneous tissues) along the urinary tract, or in other situations, which might permit of the filtration of the ordinary nutritive fluids of the body in a more or less modifled condition. — Analyses tend to show that the con- stituents of these fluids do «ot reach the urine in the proportions in which they are normally found in the body. It is also possible that chyluria may occasion- ally occur unassociated with any parasite, but this remains to be demonstrated. CICATEIZATION 253 Prognosis. — Persons have been known to suffer off and on from this affection for from one to fifty years. This would suggest that the malady usually runs a chronic course, which as a rule it doubtless does ; on the other hand patients ap- parently in fair health otherwise have been known to die very unexpectedly' from no recog- nised acute disorder. "With regard to the pro- spect of a cure a very guarded opinion should be given, as the probability is that the complaint will return again and again so long as life lasts — even when the disease commences at a very early age, and often after a complete change of climate and avocation. Treatment. — This has proved extremely un- satisfactory in almost all the cases recorded ; in fact it cannot be distinctly stated that the course of the disease has been materially modified, much less cured, by any known remedy. Iodide of potassium has been tried in large doses, and in some cases appears to have been beneficial ; in others the tincture of the percMoride of iron has seemed to be more successful. A decoction of the bark of Ehizophora racemosa (mangrove) has a reputation in Guiana, just as a decoction of the seed of Nigella sativa (used also as a condi- ment in curries) has in India. The latter remedy has, however, been known to be powerless in mitigating the malady even in cases where on former occasions it had been resorted to with apparent success. Perhaps the most satisfactory results which have been published are those which have followed the administration of large doses of gallic acid — one or two drachms a day. See Pila- EiA Sanguinis-hominis. Timothy Lewis. CICATEIZATIOBT (^cicatrix, a sear) is the process by which solutions of continuity in an organ or tissue are repaired. These solutions of continuity may be due to injury, ulceration, ex- travasation, or the effusion of inflammatory pro- ducts. The result of the process is the formation of a cicatrix or scar. Pathoioot. — Cicatrization, as it occurs in superflcial parts in surgical practice, may be selected as affording a typical illustration of the process. It is most frequently and easily observed, and it corresponds to what is met with in deeper tissues. Eepair may take place either with or without the occurrence of granulation, and the process of granulation may or may not be accompanied by suppuration : the existence both of granulation and of suppuration depending on the degrees of abnormal stimulation to which the injured tissues are subjected. In an incised wound favourably circumstanced as to vascularity of tissue, absence of tension, and apposition of edges, epidermic continuity may be re-established in thirty-six to seventy-two hours. The lips of such a wound are temporariljr united by a thin layer of lymph and white corpuscles of the blood, and perhaps soon afterwards by cells proliferated from connective-tissue corpuscles, These cells become spindle-shaped, and are ulti- mately converted into ordinary connective-tissue corpuscles, whilst offsets from the neighbouring capillaries re-establish the circulation throughout the new tissue. Coincidently with these changes the surface becomes covered with epidermic scales. 254 CICATRIZATION. The resulting Bear at first appears as a red line, which subsequently becomes -white from the dis- appearance of many of its blood-vessels. When an open wonnd heals by scabbing, the epidermis spreads over the tissues without the intervention of the process of granulation, owing to the protection afforded them by the crust of blood and lymph which has formed upon the wound. Eecent antiseptic surgery has shown that even large hollow wounds filled with blood-clot, such as are caused, say, by operation for ununited frac- ture of the femur, may cicatrize completely without suppuration or granulation, if protected from the stimulation of the antiseptic used. In these cases the white corpuscles of the clot become organized directly into fibro-plastic cells and connective-tissue corpuscles, and the new epidermis will probably be formed beneath a thin upper layer of the clot. If a recent wound, too large for scabbicg, be simply left exposed to the air or treated with water dressing, or with an ordinary antiseptic, there will be a discharge at first of serum tinged with blood, then of pale serum, and latterly of cloudy yellowish serum, replaced in about three days by fully-formed pus. By this time the wound will be studded over with little bright red ele- vations, termed granulations, which ultimately cover the whole surface. Granulation-tissue consists of nucleated cells, amongst which pass vascular loops with thin walls. After an inter- val the edges of the skin are seen to be on a level with the granulating surface, and as it were continuous with it. Perhaps already the wound is much smaller, owing to the shririing of the granulations as their cells assume the spindle-cell type. Then, extending from the cutaneous mar- gin there may be observed a narrow red line, brighter than the rest of the granulating surface, owing to the presence of a layer of transparent epidermis. Next day this zone will be bluish, owing to the growing opacity of the epidermic cells, and there will be a new red line of newest epithelium. A day later the outer layer will have become so opaque as to be whitish, and the second to be bluish ; and there will again be a fresh inner red line, which will gradually advance until the soar is complete. The new epidermis quickly separates into a horny and a mucous layer. The healing of an evacuated abscess-cavity depends partly upon the contraction, and partly upon the coalescence of the granulations of which its pyogenic membrane consists. Many cases of disease of joints (caries, &c.), and the behaviour of abscesses treated anti- septically and with adequate drainage, may be referred to as instances of the existence of non- suppuiating granulations. John Bishop. OUTOHOWISMt.— A condition induced by the administration of quinine, the chief active principle of cinchona. See QniNiNiSM. _ OIlirCLISIS {Kiy\lCa, I move).— This word signifies agitation or motion, and was formerly applied to involuntary winking or movements of the eyelids ; and also to the movements of the chest in dyspnoea. CIBOULATION, Disorders of.— Abnor- CrRCULATION, DISOEDEKS OP. mal excess and deficiency of Hood are known as Byfertemia and Anamia respectively. Each of these may be general or loeal. I. Hypersemia.— General hyperemia sighifiei excess of blood in the body, and is also called plethora. Local hypersemia means excess of blood in a part. Such excess may be caused either by superabundant supply, or by deficient removal of blood through the agency of the blood-vessels. Dilatation of the arteries, how- ever produced, causes more copious afflux of blood, which fills the capillaries and veins in a corresponding degree, so that there is excess of blood in all the vessels of the part. This con- dition is called arterial or active hyperenSa, active congestion, or determinatioti of blood. If, on the other hand, blood is imperfectly removed by the veins, these vessels, as well as the capil- laries, become gorged, and the condition called venous or passive hyperemia, or vmous con- gestion, results. There cannot be capUary hypercemia, except as the result of one of these conditions. A. Arterial or Active Hyperamia, — An excessive amount of blood can be conveyed by the arteries only under two conditions : — (1) Enlargement of these vessels by relaxation of their musculai walls ; (2) Increased pressure within them, from obstruction of collateral channels with which they communicate, i.e. collateral hypersemia. (1) Relaxation of the muscular wall's may he caused directly by violence or by warmth, as is illustrated in the redness of the skin produced by a blow, by heat, or by the reaction after intense cold. Sudden withdrawal of pressure has the same efiEect, as is sometimes seen on evacuating a hydrocele or fiuid-colleetion in s serous cavity. Dry-cupping produces similar but more complex results, the veins being acted upon as much as the arteries. Belaxation of the muscle-fibres is produced also indirectly through the vaso-inotor nerves. If these are paralysed, relaxation of the fibres occurs, and the arteries dilate. Experimental section of the cervical sympathetic in animals shows this most clearly; but the same result follows less con- stantly if other nerves containing vaso-motor fibres are divided or injured, such as the mixed nerves of the limbs, or branches of the trige- minus. Wounds of the brachial plexus have beeu found to cause hypersemia of the fingers {^loisy fingers of Paget). When the section is com- plete, hypersemia is only transitory, and is soon followed by a return to the normal condition, or even by undue ansemia, which is permanent In irritative lesions, on the other hand, such is gunshot wounds, hypersemia continues as Mg' as the irritation. In such cases it is possible that the lesion is not paralytic, but depends upon stimulation of the actively-dilating vaso- motor fibres which physiologists have now shown to exist in many parts of the body, since stimu- lation of these produces the same result as paralysis of the inhibitory fibres. Hypertemia often accompanies neuralgia, both depending upon some morbid condition of the nerve, ^he starting point of the neurosis in all these cases may be, and often is, in the central nervous system, and hence chronic diseases of the' spinal cord or brain are often accompanied by general CIRCULATION, DISOEDEES OF. 266 IMiralytichyperaemia— that is, flushing, or by con- eestion of special parts. The same result may come from reflex nervous action, set up by dis- turbances of the digestive organs, the organs of generation, or of other parts. (2) Collateral hypersemia is a consequence of the rise of pressure produced by the blocking-up of arterial channels in the adjoining parts. _ It is usually effected by the enlargement of existing vessels, and the conversion of small, almost capil- lary, vessels into pulsating arteries. It occurs not only in the familiar instances of surgical ligature, and the sudden blocking of an artery by a plug (see Embousm) ; but in the gradual obstruction which accompanies atrophic and sclerotic processes. When the chief arterial channels to an organ become obstructed, its peri- pheral parts are very liable to become hypersemic, a principle which when applied to such cases as cirrhosis of the liver, granular kidney, and sclerosis of the brain, will be found fruitful in practical deductions. Signs aud Eestjits. — The colour of parts in a state of active hyperemia is, during life, bright red, the arteries, large and small, being visibly injected, while the capillaries, filled with arterial blood, produce a diffiise rod colour. In experimental hyperaemia the blood may remain bright red even in the veins. The temperature of external parts becomes elevated, though not above that of internal parts. Sometimes there is obrious pulsation or throbbing. There may be swelling, which is due to simple enlargement of the vessels, not to exudation of fluid, since this does not occur &om artyrial hypersemia alone. The nerves, both those of common sensation and those of special sense, are more excitable than they are normally. There is usually a subjec- tive sensation of warmth, and there may be pain or itching. Arterial hyperaemia may last for a long time without producing any change whatever in the part affected, but may, under conditions little understood, give rise to hypertrophy, ■which some- times, though rarely, results from section of the cervical sympathetic. Transitory but repeated hyperaemic conditions more regularly produce this result, as is seen in hypertrophy from pressure ; in thickening of the skull from excessive exposure of the head to the sun ; in hypertrophy of the skin and its glands from frequently recurring hypersemia of the face (acne rosacea). This kind of hypersemia constantly precedes, but can hardly be said to produce, inflammation. It does, how- ever, render the tissues more vulnerable, bring- ing them into a condition in which a slight cause will set up inflammation. Unless the vessels are unsound, simple arterial hypersemia does not lead to haemorrhage. B. Passive Syferamia or Venous Congestion. — This maybe due to— (l),I'e«ble circulation; or (2) Obstruction in the veins. (1) Blood may be imperfectly removed from a part, owing to the imperfect action of the forces which normally maintain the flow of blood in the veins. These are, besides the action of the heart, the pressure of muscles (combined with the arrangement of the valves in the veins), and the movement of the thorax in inspiration. If these are deflcient, the venous current will be everywhere delayed, but notably in those parts where it has to overcome the action of gravity. In the erect posture this will be the case in the lower limbs, and hence venous congestion is com- mon in the legs, ankles, and feet. In decumbent patients, for an^ogous reasons, the nates, sacrum, shoulder-blades^ and the bases of the Itings behind become the seat of what is called hypo- static congestion. Very general obstruction, such as results from imperfection of the heart itself, may lead to the condition called cyanosis, which is essentially venous congestion, and to similar oongesticn of the lungs, liver, kidneys, and other internal organs, with very serious results, (2) Obstruction of the veins is rarely produced by a morbid condition of the walls of these vessels, but may result from coagulation of blood within them. Another cause is external pressure, such as that of tumours, of the gravid uterus, or of the intestinal contents, as in the ease of the haemorrhoidal veins. Finally, indurative changes in the solid viscera lead to venous obstruction, as is seen in cirrhosis of the liver, which produces congestion of the whole portal system. Signs and Eesults. — The colour of parts in a state of passive hyperaemia is bluish rather than red, the veins, large and small, being in- jected with venous blood, and the capillaries, in which the blood is also venous, producing a uniform purple colour: If the congestion is extreme, collateral venous channels are likely to be established, which are sometimes the only evident sign of internal venous obstruction. The surface is usually cooler rather than hotter when compared with corresponding parts of the body ; and there is no unusual nervous sensibility or sense of throbbing. Swelling very frequently occurs, and depends on actual serous effusion from the vessels, so that the parts are often anasarcous, pitting on pressure ; while in cavities there is an accumulation of fluid. Venous congestion produces more important and permanent results than arterial. In experi- mental venous obstruction, besides engorgement of the vessels, two nearly constant phenomena are seen — copious transudation of serum, and migration of a number of red blood-disks through the walls of the capillaries and smaller veins. Few or no white corpuscles emigrate, and the arterial circulation is unaltered. The absence or occurrence of dropsy depends upon the ade- quacy or inadequacy of the lymphatics to carry off the superfluous serum. In ordinary patho- logical venous congestion all these changes are seen to some extent ; extravasation of red blood- disks being shown by the pigmentation of parts in chronic congestion , though this is not evident in the acute condition. Chronic venous congestion increases the hardness and density of organs, a change which may, in the first instance, result from simple oedema, but in the end is due to fibroid change (see Degeneeations). Such organs are at first enlarged, but ultimately diminish in size, and suffer fatty atrophy, not only through the general law of fibroid change, but because, venous blood is inadequate to the proper nutrition of tissues. These changes are seen in the liver and kidneys in cases of obstruc- tive heart-disease. External parts, as the skin of the lower part of the leg, show by a tendency 2S6 CIRCULATION, DISORDERS OF. to ulceration that they are imperfectly nourished, and are also liable to becomo inflamed from Blight causes (varicose eczema). PosT-MOETBM Charaoteks. — The appearance of hypersemie parts after death is not neces- sarily the same as during life. The colour of the blood does not enable us to say whether the hyperaemia was arterial or renous. All blood contained in the body after death, excluded from the air, is dark or venous, but becomes florid when exposed to the air, unless it have previously undergone some post-mortem change, or some morbid alteration during life. This change may be watched in the lungs when the chest is opened, especially, in the case of chil- dren whose lungs have little local colour. The only important point after death is the fulness of the three kinds of vejssels. Arteries are usually empty, unless diseased ; the larger veins almost always full. If the smaller veins and arteries are conspicuously and brightly injected, the part may be described simply as congested ; a uniform colour indicates fulness of the capillaries, which may be confirmed by the microscope. Uncom- plicated arterial hypersemia leaves no trace after deati ; the appearance of it is produced by in- flammation. Simple venous hypersemia can only be recognised as such after death by comparison, that is, with the same part under normal con- ditions. Chronic venous congestion is indicated by many of the same characters as during life. Care should be taken not to mistake for arterial hypersemia mere staining with blood-piginent of the walls of the vessels; nor for venous congestion mere post-mortem hypostasis, or the settling down of the blood, if fluid, after death. II. Ansemia. — General anaemia is a morbid condition in which there is a deficiency of blood, or, more correctly, a deficiency of the red cor- puscles of the blood, throughout the whole body. It is also called oligemia, or oligocytliiEmia (see Anemia). Local ansemia, with which we are here concerned, signifies deficiency of blood in a part. It may be complete or partial. Complete local ansemia can only occur when the blood-supply of a part is totally cut off by obstruction of its arteries. The conditions and consequences of such obstmo- t ion are discussed elsewhere (see Embolism.) Par- tial ansemia or iscAismia may be produced by direct pressure, or else by arterial obstruction, perma- nent or transitory. Permanent ansemia of many parts results from gradual obstruction of arteries by atheromatous change, or, still more strikingly, by a form of endarteritis (endarteritis obliterans) attributed to syphilis ; or, again, from deposi- tion of fibrin on the diseased vascular wall. Temporary ansemia results from spasmodic con- traction of the annular fibre-cells in the muscu- lar coat of the artery. Such a contraction may be produced experimentally by direct electrical stimulation, or by stimulation of the sympathetic branches distributed to the vessel ; and in pa- thological conditions we find such contraction occurring in consequence of some derangement of the nerve-centres, or from reflex irritation, or even, as it would seem, idiopathically. Neu- ralgia and migraine are often accompanied or caused by spasm of the arteries, and epilepsy has, with less certainty, been attributed to the eame cause. In these cases it is possible, as is CIRCULATION, ORGANS OP. held by some authorities, that ansemia of the nerve-tissue is the cause of the disturbed inner- ration. Hysterical blindness, and probably other hysterical afiSections, may be explained in the same way. SiGKS AND Eesults, — An anaemic part is pale, its temperature in the case of external parts is diminished, and there is weakened or arrested arterial pulsation. A permanent con- dition of anaemia, even if only partial, produces degeneration, ending in atrophy of the affected part. The wasting of the skin, and possibly that of the kidneys in old age, is due to this cause. Transitory ansemia causes necessarily a cessa- tion of functional activity, in the part, as ia obvious in the nerve-centres and the muscles ; but does not, so far as we know, produce any permanent change. Compression or obstruction of the abdominal aorta produces symptoms of temporary paraplegia. J. K. Payhb. ' ;, CIROTTIiATIOir, Disaases of Organs of. The organs of circulation comprehend, the heart, the arteries, the veins, and the inter- vening capillaries. The diseases affecting each of these structures will be found described under their respective headings. It has, however, been thought desirable to give in this place a general sketch of the different ways in which the inti- mate relations that exist between the parts of the circulatory apparatus maybe disturbed bydisease. While the heart, the arteries, the veins, and the capillaries have each special diseases, related to their differences of structure and of fdnction, the effect of such diseases is rarely or never purely local. The otheJ* parts of the circulation on either side of the lesion and the regions to which the vessels are distributed suffer more or less from the local disease. This is true whether the disease be structural or only functional; and whether, in the latter case, the nervous system or the blood be the primary seat of the disorder. Viewed thus, the subject will be best considered under three heads : — 1. The structural changes of the several organs of circulation, and the diseases and disorders to which they give rise in other parts of the system, whether general or local. 2. The functional disorders of the organs of circulation due to nervous disturbance, both local and general. 3. The fmuiiional dis- orders of the circulation due to changes in the blood. We shall discuss these divisions in the order in which they have been named, (A) — Stktjctuhal Chanobs in the Orbaws of CiEonLATioN. — The heart is liable to organic disease either in its propelling muscular walls, its regulating valves, or its controlling nervous sys- tem ; and it will be found that diseases of each of' ' these parts of the cardiac apparatus affect respee-'" tively its several functions. Thus disease of the walls of the heart affects the force or pressure ; valvular disease primarily disturbs the distribu- tion or quantity of blood in the several parts of the circulation ; while nervous disorder especially in- terferes with the rate and regularity of its move- ments. Diseases of the arteries interfere with the quantity of blood transmitted through them, and produce secondary disturbances of distn- bution or of pressure. When the oapiUary walls are degenerated or ruptured^ or when their canal) CIECXJLATION, DISEASES OF OIIGANS OF. 257 st important group of cases is that in which the blopd contains some poison, whether generated within the body or introduced from without. The disturbances of the circulation by poisons of all kinds ane very numerous and complex. When the poisoning of the blood is CIEBHOSIS. of long duration, and moderate in degree, chrcnie disease may be set up throughout the organs of circulation ; and this ia probably the mode of origin , of the cardio-vaseular disease .so often found accompanying chronic Bright's disease. B. QtTAiN, M.D. CIEKHOSIS (k#^s, yellow).— Sinon.': Sde- rosis ; Pibroid Substitution; Fibroid Degene- ration ; Chronic Interstitial Inflammation ; Ir, Cirrkose ; Ger. Cirrhose. ., ^ The term cirrhosis, which- was origjnallyjiii. vented to describe a particular state of theiliver has now acquired a more extended meaning, and is applied to similar morbid processes affect- ing other organs, though the name itself derived as it is from the yellow colour of the liver in this disease, ceases to be properly applicable. Cirrhosis may be regarded as a chronic non-suppurative inflammation affecting the interstitial, connective, and supporting tissues of the different organs, and not those by which the proper physiological function ia per- formed. The process begins, after a more or less protracted hypersemia, by the appearance in the interstitial tissues, between the proper functional elements, of small lymphoid cor- puscles or leucocytes, which are arranged in lines or tracts interpenetrating the affected organ. , These corpuscles crowd the tunica adventitia of the small vessels, the lymph- spaces, and the cavities in which the connective- tissue corpuscles lie ; and when present: in, con- siderable amount appear to the naked eye as narrow lines of a slightly translucent, greyish material. This condition was formerly termed cellular hyperplasia of the connective tissue,«nd the corpiisdes themselves were supposed; to originate from proliferation, of the connective- tissue corpuscles. More recent researches have, however, shown that in inflammation the connec- tive-vtissue. corpuscles remain quite passive and) take no part in the formation of new cells. The early stage of cirrhosis is therefore more correctly described as cellular infiltration of the connective tissue. The cells themselves are white blood-globules, which have emigratedfcom the vessels, and their descendants. The amount of this cellular exudation varies very much in different organs in the different forms of the. disease. In many cases of cirrhosis of the liver, and in the fibroid induration of the left ven- tricle of the heart, and of the pylorus, it is very considerable, and causes much increase in the bulk of the affected organ. In other instances, as in some forms of granular kidney, it may be very small. Many pathologists consequently . regard the process ia these cases fis essentially one of atrophy of the true physiological tissue, and the indurated fibrous tissue which results as consisting of the withered remains of the vessels ducts, &e. of the organ. The later stages of the process consist in the conversion of these tracts, which may be looked upon as closely analogous to ordinary grannla- tion-tissue,_into fibrous tissuoL A more or less fibrillated intercellular substance appears^ the corpuscles diminish in number ; the remaining ones become in part elongated and oar-shaped, and some may pass into true spindle-cellBi oi>» CIRRHOSIS. become stellate : in cinhosis of the lung tracts of true spindle-cell tissue are often met with. In the liver, ■where much of this new tissue is often formed, numerous blood-vessels become developed in it: they are devoid of distinct walls and consist merely of channels lined by endothelium. The fibrous tissue which is the final result of the whole process, closely re- sembles ordinary cicatricial tissue ; it is usually tough, dense, and imperfectly fibrillated, with a strong tendency to contract. Sometimes, especially in the suprarenal capsules, and less frequently in the liver, portions of it consist of a reticulated connective tissue. The effect of this series of changes on the proper physiological tissue of the organ is to cause its atrophy; This is partly due to the direct pres- sure of the new growth, when it is formed in large quantities, but chiefly to the constriction of the contracting fibrous tissue and the consequent ob- literation of the blood-vessels; for even where, as in the liver, new vessels are developed, the origi- nal vessels of the organ become obliterated. The atrophy of the proper tissue of the organs ap- pears to take place by a gradual process of granu- lar and fatty degeneration followed by absorp- tion. Sometimes, particularly'in the lungs and supraxenal capsules, this change is less gradual,' and portions of the original tissue together with the new growth lose their vitality m masse, pass at once into a state of fatty degeneration, and ultimately become caseous and even calcareous, giving rise to the formation of ^ opaque-yellow nodules surrounded by the semi-t]^ansluc6nt grey fibrous tracts. In these cases it becomes difficult to draw a strict line of demarcation between cirrhosis and true tuberculosis, and the difficulty is rendered greater from the fact that chronic tuberculosis in itself sets up the cirrhotic process. In the lung the caseous transforma- tion is no doubt most commonly caused by the filling up of the air-vesicles with large epithelioid catarrhal cdls (»)ineidently'with the ciSrhotiC' change' in the walls of the vessels. These catarrhal cells not being in immediate relation with the blood-vessels, are especially prone to caseous change. So, too, in the suprarenal capsules the caseous nodules, if examined early enough, will be found to consist of the tubular spaces of the organ filled with their cells in a state of fatty degeneration'. In the liver, on the other hand, the secretory cells, being in intimate relation with thie blood-vessels, are not liable to this caseous transformation^ Again, it is impossible to make a strict demarcation be- tween Syphilitic affections of the viscera and true cirrhosis. ^ Even the typical gummata of sfyphills briginatie in kM are surrounded by tracts of cirrhotic induration ; and in other cases where true gummata are not found, the only difference between cirrhosis and syphilis is that in the latter there is a greater accumulation of the new growth afparticular points aUd a less geUeral diffusion of it through the oi-gan. Lastly, in some 'caaes, as in 'the cirrhotic liver Of hereditary syphilis, the two processes are identical. If we now proceed to inq'uire into the eauses of arrhosis, wefind this,t'it is generally preceded by R protracted hypersemia of the affected organ produced by some chrom'c irritation, whether CIVIL INOAPAOITY. 259 functional or mechanical. As examples of this may be mentioned cirrhosis of the liver which results from the congestion produced by spirit- drinking | sclerosis of the grey matter of the cerebral convolutions after protracted maniacal excitement ; cirrhosis of the lung, the result of prolonged inhalation of irritating dust in the various forms of grinders' and miners' phthisis ; the cirrhotic thickening of the pylorus in chronio catarrh of the stomach ; and cirrhotic affections of the lungs and heart extending to those organs : in chronic inflammation of their serous coverings. A mere passive congestion, however, if long continued, may cause a simple hypertrophy or overgrowth of the interstitial connective tissue, and more or less induration in consequence. It does not, however, appear to have the same tendency to excite active proliferation and the formation of the contract- ing fibrous tissue characteristic of true cirrhosis. The exception to this rule is that we usually meet with ■ a slight . degree of the cirrhotic change in cases of ' nutmeg ' atrophy of the liver due to prolonged passive congestion of the hepatic venous system. W. Cayiet. OIBKHOSIS OF LIVBB, LUBTG, &o. See L;vEE, Luso, &c.. Diseases of. , , ■ Ciyiti INCAPACITY.— One of the causes of this condition is mental weakness or disease, and it is one of the duties of the physician to aid in determining the existence and nature of such conditions. There is a kind of iucapacity which is implied in the restriction of a perison'g liberty when he is placed under care inanasylum or other special place of treatment. The neces- sary information regarding this will be found in the article Lunacy, Laws of. But the question of Incapacity is more directly raised when it is proposed that a person? should' be declared unfit to exercise his civil lights, to require the shield of the law to prevent his being imposed on, and to obtain special protection for his pro- perty.- Medical evidence will req'uire to be taken if it becomes necessary for a Commission of Lunacy to be issued by the Lord Chancellor; This is a proceeding which ought not to be adopted if it can properly be avoided. But it must be remembered that till a person is found lunatic by ! inquisition he may, though placed in an asylum under regular certificates, exercise his rights un- ' restricted in the disposal of his property. The acts of any person either in or out of an asylum ;may, however, be declared invalid if it can be i shown that at the time they were performed the 'person laboured Under sUch an insanity as i rendered- him incapable of performing them' i rationally aUd without iiijuriouS consequences. On this principle any person may be found to have been incapable of cotitracting marriage, of ! executing a 'deed, contracting' a debt, making a 'will, or giving credible evidence. The" principle, |it must be' ca'refully noted, is not that the mere ; existence of Insanity in the person performing I them invalidates such actions, but that if the i insanity has materially affected the character : and quality of the actions they may be thereby' I invalidated. This is one of the most important ■ principles that a medical jurist has to keep in mind, as it is not an unfrequent mistake to sup- 260 CIVIL INCAPACITY. pose that a, person is necessarily incapacitated for the performance of every civil act the moment he can be proved to lahoxir under any condition to Vhich the term insanity may be applied. Per- haps the case in which the validity of a civil act is most easily endangered by the existence of any form of insanityis the contract of marriage. This proceeding is supposed so to affect the whole relations of life that almost any form of unsoundness of mind may be sufficient to inter- fere vrith that intelligent and deliberate con- sideration -which is essential to the giving of rational consent. The different kinds of mental disease will be found described elsewhere (see Ihsaniti), and it is necessary that the practitioner, when dealing with medico-legal questions, should be fuUy ac- quainted with them. But it is chiefly important that he should distinguish the two following classes: (1) diseased perversion of the mental faculties, and (2) weakness or enfeeblement of the mental faculties resulting either from de- fective development, disease, or decay. The first class includes all kinds of insanity which are the result of a,ctive disease. These would be the simple forms of delirium, mania, melan- cholia, and monomania ; as well as the similar primary conditions which are found in general paralysis, and other diseases which present ma- niacal, melancholic, or monomaniaoal symptoms. It is in this class that the special knowledge of the physician can be most successfully applied in aiding the administration of justice. In order to establish the incapacity of a person said to labour under any of these forms of disease, it must be necessary that an expeidenced physician should not only be able to detect their charac- teristic symptoms, but also to show that the perfbrmance of the duties or the exercise of the rights under consideration would be modified or obstructed by the existence of such disease. The second class includes congenital imbecility, and all the forms of what is called chronic dementia — all those enfeeblements of mind which are some- times the remaining effects of acute disease, some- times the concomitants of chronic disease, and sometimes only the mental phase of senile decay. Here, again, the information which maybe com- municated by the physician must be of great importance. But in estimating the extent to which a condition of mere mental weakness will disable a person from the performance of a cer- tain class of actions there is not so much special medical knowledge required as is necessary in the consideration of active disease. Marriage. — As has been already stated, the mere existence of any form of insanity in one of the parties may render a contract of marriage void. In one case which terminated in this manner, a man who had been insane and when in that state had voluntarily contracted marriage instituted the suit himself. Civil Contracts may be held binding although made by lunatics. If the person with whom a contract is made had no knowledge that the person contracting was insane, and if no attempt was made to take undue advantage of him, the contract would be held good. Wills.— A person is considered to be of a dis- posing mind, that is, capable of making a valid will, if he knows the nature of the act which he is performing, and is fully aware of its conse- quences. It is iii regard to the making of wills that the law has carried out most thoroughly the principle that the validity of an act .ought to be maintained in cases of insanity unless at the time the act is performed the state of mind of the agent can be shown to render him unfit to perform that particular act in a rational manner. Persons have made valid wills while inmates of lunatic, asylums. And one will was held to bs good though the testator had committed suicide within three days after its execution. The ex- istence of delusion which has been regarded by lawyers as of such importance in cases of al- leged insanity does not invalidate a will ; for it has been declared to be ' compatible with the retention of the general powers of the faculties of the mind,' and to be ' insufficient to overthrow the will unless it was calculated to influence the testator in making it.' On the other j hand, a will may be invalidated on account of the exist- ence of mental states which would not be re garded as insanity from either a legal or medical point of view. Drowsiness and stupor resulting from erysipelas or fever, extreme weakness from cholera, and failure of memory in old age, have all been found sufficient to render wills void. It frequently happens that a medical man is called on to be witness to a will. On such an occasion it is his duty to satisfy himself as to the tests- mentary capacity of the testator. His subse- quent evidence in regard to this, will, in case of dispute, be of almost decisive influence if he has taken proper means of forming an opinion.. In all cases, therefore, where there may be a possi bility of doubt it is well to require the testator to show that without extraneous aid, and \ritli- out referring to the document itself, he remem- bers and imderstands all the provisions of the deed. Evidence of the Insane. — Lunacy was, till a recent date, regarded by the law as incapacita- ting a patient from giving evidence. in court. But according to the much more extended sig- nification which the term lunacy has received it now includes states of mind which are looked on as compatible with testimonial capacity. Where the judge is satisfied that the luuatiis understands the obligation of an oath, and can give a rational account of such things as happen before his eyes, the evidence may be admitted. But the weight to be attached to such evidence wiU still depend on the extent to which it fulfils the conditions commonly required to constitute credibility. It has, been held, however, that when a person has suffered from an attack of insanity between the occurrence of the transaction and the time he tenders his testimony, his evidence cannot be admitted. Manof/emmt of Properti/. — Where persons are supposed to be unable from unsoundness of mind to undertake the management of their own pro- perty, it may be necessary that they should' be placed under the protection of the Court of Chancery; but this proceeding is not usually had recourse to unless there is urgent necessity or a strong probability that the person's incapacity will be permanent, It is consequently resorted to chiefly in chronic or congenital cases whew CIVIL INCAPACITY. there is no room for doubt as to the mental con- dition of the individual ; and in cases of recent insanity where it is necessary to have recourse to an asylum for the protection of the individual it may also be necessary to obtain protection for hia property by the aid of the Court of Chancery. In giving evidence or framing a statement in such a case it is important, if incapacity is to be proved, to show that the individual has been found, when placed in cir- cumstances requiring such capacity, unable to perform the acts which the management of property necessitates. In cases of active in- sanity it is especially required to show, not merely that there is delusion or other symptoms of insanity, but that the insanity is of such a nature as specially to disable the person from duly performing the duties which would be re- quired of him. Difficulties most frequently occur in cases of imbecility and dementia ; but the ver- dicts in such cases when disputed will generally be foimd to rest rather upon the impression pro- duced by evidence of the actual behaviour of the individual than upon the mere medical view of his mental condition. The most effectual aid that the medical witness can render in such cases is to show whether there are or are not such pecu- liarities in the conduct of the person under inquisi- tion as are known to be chaiactferistic of imbeciles or demented persons. In undisputed cases, where the duty of the medical man consists merely in making an affidavit, there is no special difficulty to be encountered. Brevity, scrupulous accuracy, and attention to the fact that such unsoundness of mind as involves incompetency to manage pro- perty must be established, are the most important requirements. A person found by the court to be incapable is placed under the control of a ' committee of the person,' and the property under a ' committee of the estate.' In Scotland an application to the Court of Session for the ap- pointment of a Curator bonis takes the place of the English inquisition. The chief peculiarities of the Scotch process are that it is cheaper, more easily effected and more easily annulled, and that it does not affect the person of the lunatic. The functions of the curator correspond to those of the committee of the estate in the English court. The Scotch procedure for the appoint- ment of a guardian of the person was virtually in desuetude until the passing of a recent statute (31 and 32 Viet., cap, 100). Under this act a brieve for the cognition of an al- leged lunatic is issued from Chancery and tried before a judge, of the Court of Session and a special jury.. The procedure is similar to that of jury trials in other civil causes in Scotland, and both medical and other evidence must be produced. . If the person so cognosced be found 'furious, fatuous, or labouring under such un- soundness of mind as to render him incapable c( managing his affaire,' his person is placed under the guardianship of the nearest male relative found competent. Drmkenness. — This condition is not held to deprive a man of civil capacity unless it has at the time rendered the individual unconscious oi what he was doing. J. Sibbauj. CLAP. — A popular name for gonorrhoea. See GoNORRH(EA. CLIMATE. 261 0LAVT7S HYaTBBIOTTS (cZaoiw, anail),— An acute pain often associated with hysteria, but occurring also in other conditions, which is felt in a localised point in the head, and is compared by the sufferer to the sensation that might be produced by a nail being driven into the part. See HysTERii. OLIMACTEKIC (kAi^oktV, astep, n\ifuiCi», I proceed by degrees, or step by step). — This word, which properly signifies 'by degrees,' was originally employed to indicate certain epochs or periods in the life of an individual, which were looked upon as critical, and at which the body was supposed to have undergone a complete change, so that it had become entirely renewed in its structural elements. The years in which these epochs terminated were called climacteric years — anni cUmacterici, and their number was variously estimated. Thus, some only recognised three climacterics ; the Greek physiologists held that there were five, ending at the seventh year, the twenty-first (7 x 3), the forty-ninth (7 x 7), the sixty-third (7 x 9), and the eighty-first (9 x 9^ others made them multiples of seven or nine, or multiples of seven by an odd number. Most regarded the sixty-third year as the grand cli- macteric!, but the Greeks recognised two grand climacterics, terminating respectively at the sixty-third and eighty-first years, and this special denomination was given because there was little, if any, prospect of life being extended beyond these periods. At the present day the word cli- macteric has lost much of its original meaning, and is generally applied to certain times of life, without any reference to numbers of years, at which marked physiological or developmental changes occur, such as the period of puberty, or that of the cessation of menstruation. A particular climacteric disease has been de- scribed, which is said to occur, either about or siibsequent to the sixty-third year or grand cli- macteric, and supposed to be distinct from the natural decay and degeneration which takes place in advanced life, inasmuch as recovery often ensues. It ie stated that , the complaint comes on suddenly, but advances insidiously, the symptoms being at first loss of flesh and weakness, followed by loss of appetite and dys- peptic symptoms with a white tongue, which are regarded as sympathetic, sleeplessness or disturbed and unrefreshing sleep, constipation, pains in the head and chest, a frequent pTilso, swelling of the legs, and an emaciated or bloated appearance of the face. The urine does not present any ab- normal characters, and most of the viscera seem to perform their functions properly. Whether there is any independent disease deserving this special denomination seems to the writer to be more than doubtful. FliEDEElCK T. EoBEETS. CLIMATE, .Etiology of. See Bisease, Causes of, CIiIMATE, — Formerly the word climate (from the Greek word k\Ii/u, I incline) was a term of astronomical or mathematical geography, which implied a portion or zone of the earth's surface comprised between two lines parallel to the equator, and measured by the length of time during which the sun there appears during the 262 CUMATE. summer solstice, that is, by the sun's inclination. The space between the equator and the pole was divided into half-hour climates, in which the length of each day increased by half-au-hour, and also into monthly climates. This unequal division of each hemisphere is now replaced by a-division of the interval between the equator and the poles into ninety degrees, which constitute what are called degrees of latitude, and the word climate has received a more extended application. By climate is now understood those conditions of heat, moisture, atmosphere, wind, soil, and electricity, which impress certain conditions, uni- form even when apparently irregular, on given portions of the earth's surface, and' which inodify, also in a uniform manner, vegetable and aniinal life. Climate, when thus interpreted, is still princi- pally dependent on nsti:onomical facts, on the sun's position or inclination with regard to the earth, and on the amount of heat it supplies to different portions of the surface of the latter. Climate may be studied generally and locally. The division of the earth's climates is necessarily arbitrary, and many different classifications have been proposed. The most simple is that which recognises three principal kinds of climate, each susceptible of subdivision, viz. : warm climates from the equator to 35° lat., temperate climates from 35° to 60° or 55° lat., cold climates from 50° or 55° to the pole. As subdivisions we may recognise equatorial, tropical, sub-tropical, sub- polar, and polar climates ; and also insular and maritime, or moist climates— continental and ' mountain, or dry climates. 1. Warm climates, extending from the equator to 35° lat., that is, 1 2 J° beyond the tropics, com- ' prise nearly all Africa and its islands. South Asia, most of the islands of Polynesia, and the portions ' cf North and South America comprised between California and the north of the La Plata territory. In the equatorial regions the medium temperature for the year is from 80° to 84° P., the man. beiiig 64°, the max. 118°- Near the equator the annu^ mean temperature decreases slowly as we recede from it, the decrease not amounting to more than 2° F. for the first 1 0° lat. The difference of tem- perature during the day is slight, but much greater during the night, owing to radiation. The general variations of the barometer are slight, but the periodical or diurnal variations are very marked. It ascends and descends regu- larly twice in the twenty-four hours. It ascends from 4.13 a.m. to 9.23 a.m., and descends until 4.8 p.m., ascending again until 10.23. Electrical phenomena are very decided. The rainfall is variable, but 40 inches may be given as a mean. It is generally supposed that heat is greatest at the equator and diminishes as we recede from it ; but both observation and astronomical induction lead to the conclusion that not only the maximum of temperature in warm climates is attained at or near the tropics, but also the highest annual mean. The countries in which the highest degree of heat is known to be attained are near the tropic of Cancer, as, for instance, the banks of the Senegal, the Tehama of Arabia, and Mehran in Beloochistan. Moreover, the suow-line, or the line of perpetual snow, is higher at the tropics than at the equator. In the Bolivian Andes, near the tropic, it is 17,000 feet, whfereas in the Ecuador Andes, on the equator,. it is only; 16,060 feet. These facts, are partly explained by the unequal progress of the sun after the equinox in its course towards the tropic. In the first month it passes through 12° of latitude, in the second month through 8°. ' At the end of the seooad month, therefore, it is- 20° from the equator, and there remain only 3^° to be traversed in the third month. The sun receding from the tropic at the same rate at all places between 20° and 23^° of latitude, the solar rays during two months fell at noon either perpendicularlyi or at an angle -which deviates from a right only by 3^° at moat. Another cause which tends to diminish heat:in the regions near the equator is the prevalence of rain. For about fire degrees north -and south of the equator, in the region of the equatorial calms, there are few consecutive days in the year without rain. The principal cause both: of the calms and of the rains has been attributed to the meeting in the upper atmospheric regions' of the trade winds, north and south. They neutralise each other and precipitate the vapour they hold in solution. Eegions that lie between 5° and 10° of latitude have usually two rainy and two dry seasons. The greater rainy season occurs when the sun in its passage to the nearest tropic passes over tie zenith; lasting fi:om three to four months. ' The lesser rainy season occurs when the sun on its return from the nearest tropic approaches the parallel of the place. The rains then only last from six weeks to two months, and are much less abundant and continual. Countries more than 10° or 12° from the equator have only one rainy and one dry season ; the first begins when the sun appi^oaches the nearest tropic, and ends sonie time after, "when in its course from the tropic it has passed the parallel of the place. It lasts &om four to six months. Local conditions may modify the course of the dry and wet seasons, as is the case in India, where the dry and rainy seasons depend principally on the monsoons. The amount of rain that falls in a short time within the tropics is very great, much more so tham in more northern regions, but these heavy rains do not last continuously as is supposed. Days of continued rain, even in the rainy season,' ale rarer than in the north. Still, heavy rains ate apt to cause great inundations, and to cover large extents of low or level country" with water, causing swamps and marshes, very injurious to health. In the vicinity of the tropics there ■ is a belt, extending over several degrees of latitude, where it seldom rains. This rainless tract is precisely the region which has been already mentionM' as that of greatest heat. These -belts of rainless regjions, extending around the globe on eaiih side of the equator,' may be said to separate the conn- tries which lie on each side of the equator from the temperate zones. Thus in Africa the rains cease on the southern' border of the desert of Sahara at about 1 6° N., and begin again at 38°K. On the banks of the Nile the rain ceases about 18° or 19°, to begin "again between 28° and 29°. The Tehama, or lo-*- coast of Arabia, is all hut rainless. This rainless tract crosses Asia asfin as China, where there is no rainless- regi-on, ownSi probably, to the fact, that all parts of China he- CLIMATE. 263 tween 22-' and 30° N. lat. are traversed by high mouatain chains. The influence of -vrarm climates impresses cer- tain peculiarities on thepeoples who inhabit them. They are the abode of ^e Ethiopian and Mongo- lian races of mankind, and appear to have im- pressed the samecliaracteristics,in aminor degree, on the Caucasian races that inhabit them : a dark complexion and black hair. The inhabitants of these countries are indolent and apathetic. The functions of the skin and liver are peculiarly ac- tive, a circumstance which exposes them to severe disease of these organs. The digestive functions are sluggish, and the nervous system is alter- nately excited and depressed. Bemittent and in- termittent fevers, dysentery and yellow fever are common. During the dry season disease tends to assume the ataxic, during the rainy season the adynamic form. Pulmonary consumption is frequently met with in the towns, in contra- diction to received opinions. 2. Temperate climates may be said to occupy the zones of the earth's surface comprised between 3o° and 50° or 55° lat. They comprise south- ern and central Europe, with its islands ; the parts of Asia which extend between the Black Sea and the Mediterranean, and Japan; the greater part of North America ; a part of Chili and La Plata and Patagonia, in South America. The mean temperature may be stated at from 60° to 50°. The climates in 'which the mean tem- perature is from 60° to 68° are often spoken of as temperate, but in reality they approximate closely to warm climates. The four seasons, winter, spring, summer, and autumn, are well marked, but very variable both as to barometri- cal and theimometrieal conditions. The mean temperature in the central regions is, foe winter 38°, for spring 51°, for summer 68°, and for autumn 53°. The regions which are near the south and north limits of the temperate zones appro^mate to the meteorological characters of the warm and cold climates respectively. The periods of the year when storms, rain, and general versatility of meteorological phenomena are principally observed correspond with the vernal and autumnal equinoxes. The in- fiiwtice of a temperate climate on the human organisation is salutary, extremes of heat and cold being both trying. Thus the healthiest climates of the world's surface are found in this zone. Intense heat, or even moderate heat if persistent, throws a physiological strain on the liver, skin, and digestive system, and renders mankind prone to severe and fatal diseases of these organs. Intense cold throws a physiological strain on the lungs and kidneys, and exposes them also to severe and fatal disease. The healthiest temperate climates are those in which the winter is not very cold and the summer is not very warm, and in which, consequently, there is no great or continued; strain on any one class of organs. The diseases of temperate regions are those that are the best known, as their study and descrip- tion constitute the foundation of pathological science, ancient and modern. The climate -which, perhaps, the best deserves the appellation of temperate is that of the Medi- terranean basin.' The winters are not severe on any part of its north shores, and the summers are not intensely hot on its south shores ; at least the heat fells short of that of the tropics. There are many conditions of physical geography which conduce to this result. The north shores are protected from north winds by the ranges of high mountains of Southern Europe which skirt them, and the south shores are in close proximity to the hot, rainless tract of Northern Africa — the desert of Sahara, which favourably modifies win- ter temperature. Moreover, the Mediterranean is a warm sea, but few cold rivers of con- siderable size flowing into it from the north, a fact which increases the temperature on its shores and islands, 3. Cold climates comprise the regions which ex- tend from 60° or 65° lat, to the poles. They maybe subdivided into cold, with a mean of from 50° to 40° ; vert/ cold, with a mean of from 40° to 32° ; glacial, with a mean below the freezing point. In the austral hemisphere the zone con- tains but little known land, although the existence of an antarctic continent is suspected ; in the northern hemisphere it comprises, in Europe, the north of Scotland, Denmark, Sweden, Norway, Iceland, Finland, Lapland, Northern Euasia, Spitzbergen, Nova Zembla ; Northern Asia, and some of its large plains below 50° lat., Siberia, and Kamtschatka ; in America, Canada, including some regions below 50°, the northern lands and islands of Hudson's and Baffin's Bays, and Crreenland, In this zone the decrease of the mean temperature is much more rapid as we recede from the equa- tor, than it is in the tropical regions. Thus from the equator to 20^ lat. the variation of the mean temperatiire is not more than 7° or 8°, whereas the variation between 65° and 78° lat. amounts to from 22° to 27°. The coldest region of the globe is not, it would appear, at or near the pole, but at about 80° lat., or 10° from the pole, north of Behring's Straits : the cold of the glacial climates has been exaggerated. At the latitudes of from 70° to 78°, the extreme limit of human habitation, the moan annual temperature is be- tween 19" and 17°, i.e. 13° to 15° below the freezing point. The extreme of cold registered, however, reaches a hundred degrees or more below the freezing point. Owing to astronomical condi- tions there is great disproportion between the length of the nights and of the days at different seasons of the year; In the more northern regions, for several months in the winter the sun never appears above the horizon, and in the summer for several months the sun never disappears below it. Spring, during which the extreme cold is mitigated, lasts but a very short time, and is suc- ceeded by summer, which is in its full strength in June and July. Temperature rises rapidly from 35° to 65° and 60°. In some northern localities it rises to 86° or 90°. Under the in- fluence of the prolonged or persistent days, and of the increased temperature, the vegetation peculiar to each locality passes through all its phases with extreme rapidity, ToWarfi the end of July rain and fog reappear, and are followed by snow and intense cold, the highest expression of which is in January and Eebruary. The barometrical changes are the reverse of what obtains in the tropics. Above 60° lat, the diur- nal or periodical changes are scarcely perceptible, whereas general or occasional variations becomo 264 CTLIMATE. more marked as we approach tlie pole. Electrical phenomena become less marked, and above 68° lat. they are scarcely perceptible, with the excep- tion of the aurora borealia. The winds which pre- dominate are the N.E\ and S."W., and they change rapidly from one point of the horizon to -the other, and thus frequently occasion tempests which extend over considerable areas. The quan- tity of rain that falls in cold climates is much less than in the tropical and temperate, with some exceptions. Between 60° and 90° lat. it only amounts to a few inches, and falls principally in the form of snow. The mflumce of cold climates is shown on the inhabitants of these countries, who vary much in stature, and possess a vigorous constitution, a sanguineous temperament, great muscular development, active digestive func- tions, and sluggish nervous powers. Notwith- standing the severity of the climate they gene- rally succeed in protecting life, and live to old age, presenting few diseases peculiar to climatic influences. They are, however, subject to opththalmia and amaurosis, owing to the re- flexion of light from the snow in the polar regions, and to scrofula and scurvy, the result of a poor and incomplete dietary. Agues, and intermit- tent fevers from marsh influences, are rare, and not severe, and disappear ontirelyaa we approach the pole. Continued fevers are met with, but seldom if ever epidemically. 4. Insular climates present important pecu- liarities. The temperature of the sea is more equable than that of the land. Owing to the action of currents, and to the circulation of its waters under the influence of heat, its super- ficial temperature is warmer in winter and cooler in summer — more equable— than that of the land. It has thus a tendency to warm in winter and to cool in summer the island which it surrounds. Moreover, there is constantly watery vapour arising from the sea which extends to island atmospheres, veils the sky more or less, shields their surface from the ardour of the sun in summer, and prevents great radiation both in summer and in winter. Thus it is that the climate of all islands is more equable than that of continents. This fact is more especially recognisable in the climate of the British Isles, which is also modified — rendered warmer and moister, by the waters of the Gulf Stream im- pinging on their shores. The warm Gulf Stream, commencing in the tropics, in the Gulf of Mexico, passes northwards along the shores of North America, crosses the Atlantic to the south of Newfoundland, and strikes the shores of the British Islands, of Norway up to Cape North, of Holland, and of France ; everywhere raising temperature and the annual mean. 5. Maritime climatea ■psatici'pa.te in these influ- ences ; temperature is more equable, warmer in winter and cooler in summer, on the shores of seas and oceans than it is inland. Owing to this cause most of the winter sanitaria have been chosen in islands or on the coasts of oceans and seas : such as Hastings, Ventnor, Bournemouth, Tor- quay, Funchal, Malaga, Cannes, Nice, Mentone, Naples, Salerno, and Algiers. 6. Oonti7iental climates exhibit conditions the reverse of those which obtain in maritime climates. The tendency is to cold winters and warm summers, owing principally to the absence of the equalizing influence on temperature of large masses of water. A very short distance from the sea is sufficient to establish this differ- ence. Thus the central parts of France are very much warmer in summer and colder in winter than the coasts of Normandy and Brittany. But it is when we reach the centre of continents — Kussia, central Asia, central America — that the difference is the most marked. 7. Mountain climates. — As we rise above the level of the sea, we meet with two important me- teorological conditions. Theair becomesmoreand more rarefied, and the heat diminishes, indepen- dently of the more or less obliquity of the sun's rays. The higher we rise above the sea level the more the air is rarefied, and the more the degree of heat due to the solar rays diminishes. We arrive at last, even at the tropics or the equator, at a height, variable according to latitude> where the sun's heat is insufficient to melt the snow. This is termed the snow-line. Mountains attract clouds and watery vapour, and the coolness of their atmosphere causes the precipitation of the vapour in the form of rain or snow. Thus, mountains, moimtain-ranges, and the glaciers they contain, are the principal cause and origin of rivers. 77ie itifluence of mountain climates, notwithstanding the clouds, fogs, and rain which characterise them, is proverbially a healthy one, owing to the purity of the air, and, perhaps, to the sparseness of population. They have of late been much recommended for phthisis. The two conditions above mentioned, however, namely, purity of the atmosphere and sparseness of human habitations; are quite sufficient to account for the parity of phthisis amongst their inhabitants, and for the improvement of the phthisical who re- sort to them. Soil modifies climate considerably. Wet and marshy soils are cold, engendering fog and mist. Sandy, dry, well-drained soils are comparatively warm. All sandy plains are warm in summer and cold in winter. Such are the features which characterise the climates of the terrestrial globe, generally. Each locality, however, each mountain, plain, and val- ley, each city, village, and house, has a climate of its own, modified by all the meteorological ele- ments which we have successively considered. To discover what each climate is, we must study carefully the meteorological conditions and in- fluences which we have rapidly surveyed in their application to it. 8. Isothermal climates. — Owing to the unequa,! influence of the different elements that constitute climate, the annual mean temperature of regions occupying the same latitude on the earth's surface is very variable. Hence the above name has been given to the regions in which the annual mean is the same. The study of a map on which the isothermal lines are marked is an instructive illustration of the facts above described., Thus it will be seen at a glance that the limit of con- stantly frozen ground in -the central plains of Asia and in the northern plains of America is below 64° F., which is the latitude of York ! The general influence of climat.e.^/Dia vege- table and animal worlds, including man himself, have been modified in essential characters br CLIMATE. 26S climatic conditions. The stndy of its influence on their vitality and organisation opens out a, wide field to the observer. This study leads to the conclusion that geological periods of time have been necessary to impress on ter- restrial life, be it vegetable or animal, the cha- racteristics observed now or formerly in the climates of different regions of the earth. The current of modern research is strongly directed to the elucidation of the influence of climate on life during such geological periods. The investigations of Darwin and his followers may be named as the most remarkable and impor- tant illustration of this fact. We may also mention the researches of modern philologists, which have provedv by the study of languages and their roots, that most of the nations of modem Europe have descended from the same Aryan parents as the inhabitants of the Indian peninsula. Climate, in the course of time, has so modified them as apparently to produce dif- ferent races. For such a change to take place geological lapses of time are certainly required. Our earliest records, dating back several thou- sand years, show these races such as they are now, quite as distinct. In these days the Aryan races of Europe cannot rear their chil- dren in the climate of India, -where their Hindoo relatives thrive and propagate their species. In Palestine and Egypt the biblical records, those of the Pharaohs, and those of Nineveh and Babylon, show these regions to have been in- habited, several thousand years ago, by nations and tribes presenting precisely the same race characteristics as those that now inhabit them. During the historical period, the races of Europe have in vain endeavoured to colonise the valley of the Nile ; but they have not been able to propa- gate their species, and have died a-way, leaving the valley of the Nile to its ancient inhabitants. Their children cannot ■withstand the heat of summer. On the north-eastern shore of Africa the Algeria of the present, history presents the same record. The Eomans and the Visigoths occupied its plains for centuries, continually re- cruiting their colonies from the mother-countries ; , and yet, except in the mountains, all traces of their presence has disappeared. They could not rear their children so as to occupy the land of the Arabs. What lengthened periods of time must have elapsed to so profoundly modify races deriving their origin from a common parentage, that they can no longer live and propagate their species in the same climates 1 Therapeutical Applications. — The therapeutical application of many of the above facts is contained in the facts themselves. Reasoning suffices to deduce the therapeutical law, and experience proves the correctness of the deduction. A very brief summary only can here be given. See alto CiiMATE, The Treatment of Disease by. Firstly, it is clear that if a local climate pro- duces injurious effects on the health of its inhabi- tants, or of visitors, the latter should leave it, rtnd the regular inhabitants, who cannot leave it, should endeavour by every possible means to modify the pernicious climatic influence to -which they are exposed, and to partially escape from its action. This rule may be illustrated by the influence of confined mountain valleys in pro- ducing goitre, and of marshy districts in pro- ducing intermittent fevers. The principle ap- plies to all local climates -which exercise a pernioyous influence of any kind on the human organisation. When possible the climate should be abandoned ; if that is impossible its pernicious influence must be combated by every possible hygienic and therapeutical means. The injurious effects which extreme climates exercise on the human economy — warm climates on the abdominal and cerebral organs, cold cli- mates on the thoracic — point to change of resi- dence as au important therapeutical agent, the value of which is only beginning to be under- stood. Our naval and military surgeons have done much to clear up this branch of therapeu- tics, as regards the diseases oT tropical regions. Thus chronic affections of the liver and intestines, incurable in a vrarm climate, often become quite curable if the patient is transferred to a tem- perate region or to a mountain elevation in the tropics, -which reproduces a temperate climate. Inversely, persons suffering from diseases of the respiratory organs, so common in damp tem- • perate climates like those of France, England, and Holland, find relief by migrating, especially during winter, to -warmer regions of the earth's surface, where they escape from the influences -which have proved so detrimental to them. Thence the yearly increasing exodus of persons suffering from chronic laryngitis and bronchitis, from bronchial asthma and from phthisis, from the north of Europe to the south. The increased facilities of locomotion, by rail and by steam, have thus opened out, as it were, a new and important branch of therapeutics, that of the application of climate to the treat- ment of disease. J. Henet Bennet, CLIMATE, The Treatment of Disease by. — Though we can scarcely say -with accuracy that change of climate is a specific for disease, yet much can be effected by it in relieving symp- toms, and in assisting the reparative po-wers of the organism by thus improving the general health. The diseases in which change of climate has been found of value -will be enumerated belo-w, -with a short notice of various climates. Here we may notice the rationale of the benefit to be derived from such change. Change of climate, we must premise, is only a relative term. It does not necessarily involve the idea of removal to a great distance from the patient's home. A fe-w miles' journey from the town to the country, from inland to the seashore, from the plain to the mountain, often suffices to produce marked results. One use of climate being to expose the organism to the effects of contrast, the element of distance comes in most when we wish to make the contrast greater ; for instance, in ordering change from a cold to a warm climate or vice versd. The therapeutic elements of most importance in any climate are (1) pure air free from dust and organic particles ; (2) abundance of sunshine, without excessive heat, so that much time can be spent in the open air; (3) a temperature without extremes, so that the body is not ex- posed to the risk of great variations of heat and cold— equability ; (4) absence of violent, very CLIMATE, THE TEEATMENT OF DISEASE BY. 266 cold, orvery hot winds, at any rate of long duration (in this is involved the element of local shelter). These four elements should be present in «aeh of the subdivisions of climate •which a therar peutio classification renders necessaryi namely climate of (a) the seashore ; (i) mountains ; (c) inland -wooded districts ; (d) the open sea.. The epithets 'moist' and 'dry,' which are applied to climates, are merely relative, and depend on Ipcal peculiarities of rainfall, soil, &c., as well as to some extent on season ; and;the essential differences between the climate of the seashore, the woodland, and the mountain remain everywhere the same. We shall say a few words about each of these, with the indications for their use. The climate of the open sea will be referred to in speaking of sea voyages. (a) Climaie of the Seashore. — The special peouiiaiities of this variety of climate are that — the air is saturated with moisture, except when dry land winds prevail ; it is dense, and, as a rule, therefore, bulk for bulk, contains more oxygen than air of any higher level; its density is liable to great and frequent but regular varia- tions, which increase the activity of the circula- tory and respiratory organs, and tlius favour their functional activity ; it is more equable ; and, lastly, it contains saline particles in suspension. According to Beneke, sea air cools the body relatively quicker than mountain air, ,a,nd thus quickens the processes of tissue-change the most. Hence the seaside should be ordered where we wish for a highly stimulating effect^ as in persons of scrofulous tendency, in chronic diseases suc- ceeding acute ones, or in the later stages of convalescence from the latter, in convalescence from surgical operations, or in some surgical diseases where we wish to a£fielerate tissiie- change, without exertion on the patient's part. On account of the equability of the climate, some patients who cannot bear great changes of tem- perature do well at the seaside. Persons suffer- ing: from overstrain, mental or bodily, with a fair digestive power, and not liable to nervous irritability, may also be sent there. (6) Mountain Climates are distinguished from sea-side climates by the lower- density of their atmosphere; their lower and less equable tem- perature; by less humidity, though, owing to local winds, mist and cloud often form ; and by relatively lower night-tennperatures in clear weather, owing to the dryness of the air, and consequent great radiation. They are cooler also than the inland climates of level districts, and this coolness tends to some extent to diminish the rarefaction and, increase, the density of their air. The general action of mountain ail is to pro- duce a freer circulation of the blood and greater vascularity of the lungs, owing to deeper and more frequent inspirations and greater ease of bodily movement. Owing to the cooling of the body by the lowered temperature more food is required, the appetite improves, , and the body becomes better nourished and gains weight. The intensity of the effect is, roughly speaking, directly as the height. The term 'mountain climate ' is applied in medical parlance to eleva- tions in Europe of from 1,500 to 6,000 feet, though In South America patients have been sent as high as 10,000 feet, or higher. Honntain Climates are indicated (1) in casea ■of : hereditary tendency to phthisis in young persons with narrow, shallow chests, and who are growing too fast ; alsoi in young scrofulous patients. (2) In chronic phthisis and pneumonia; remembering, however, that phthisis occurs at all elevations. The coolness of the mountain air in the height of summer is an important .element in phthisical cases, which i, always suffer from great heat. (3) As a tonic and restorative in persons -suffering from over-work in businessi or literary •pursuits, and who have no real organic disease, (4) Generally to complete the convalescence from acute diseases of individuals not past middle life, with a fair amount of museularip(twer and bodily activity.. (6) As a prophylaotiet against hay-fever, cholerat and other iufectiousrdiseases, Mountain climates are not advisable in, leasee of chronic bronchitis, heart-disease,i emphysema, Bright's disease, chronic rheumatism,! oi for- aged persons. , (o) The Climaie of Wooded 2)isirio,k{eleyii^ofs shove 1 , 600 feet are not here referred to) is pecdiar in the following, points: — (1) It has a temperature lower than that of the surrounding country— on the average 3° Fahr. — during the hours of day- light; the temperature is also more equable. (2) The relative humidity is higher (9:3 percent) in summer than in the less wooded country, and hence there is greater liability to, rain and mist; , (3) ' It aflfords greater protection and shelter against winds than other climates. . The general effect of woodland climates, as may be, deduced from the above, is sedative and tonic. They may be advised, in chronic bron- chitis, lemphysemft,' heart-disease, and in,. hypo. chondriasis, hysteria, and, other nervous ^Sections where tranquillity and subdued light, are of importance; also in the earlier stages of con- valescence from acute disease when sea or mountain air is too stimulating. In bronchitis pine ( woods should be 'selected, and .in. heart- disease level walks are essential. , I : (d) Ocean Climates, — Sea- Voyages have of late years been much recommended in the treat- ment of phthisis in its early stages, with a view to enable the invalid to spend much time in an exceedingly pure and fairly , equable atmosphere, and to secure a sufficient amount of bodily move- ment without gireat fatigue. , The main drawbacks to the sea are the impos- sibility of escape from bad weather and the confinement to close, ill-ventilated cabins,, if such occurs ; the absence of sufficient light and air below decks, thelatter being felt very much at night; want of variety in the dieti after, ^ certain time, and at all times (except in short cruises, or coasting trips) of fresh food, milk, &c. ; monotony in society and occupations ; and, lastly, the inconveniences arising from crowding , of the maindeck -with hen-coops, sheep-pens, .&c., Iiud in steamers, from the smoke of theeng^ies, and, the smell and vibration of the maqhiinery. The routes generally recommended to invalids are either to (i\ Australia, 90 days; (2) the Cape of Good Hope, 30 days; (3) the West .Indies, 14 days; (4) the UniteiJ States or Canada (in summer), 10 days. Short croises ia the Mediterranean, or to the latitudes, >of t^e Canaries , and Azores axe suitable -jfor certaiO CLIMATE, THE TREATMENT OF DISEASE BY, 207 cases ■where expense is no object. Of routes (S) and (4) we may say that they are too short for the full benefit of the sea to be obtained, as improvement ■ does not generally begin for a week or two after sea-sickness has subsided and the patient can remain comfortably on deck. Eoute (2) does not allow him to get the bracing eifect of high South latitudes. Hence where a long sea voyage is indicated, route (1) is decidedly the best. England is quitted in the beginning of October, Australia' (Sydney or Melbourne), or New Zealand (Wellington), is reached early in January, and the return voyage is begun not later than the end of February. Patients should not remain in the coast-towns of Australia in summer on account of the heat. They should go to the table-land of New South Wales, or to Darling Downs in Queensland, or else they should cruise from port to port, or run over to New Zealand or Tasmania. In returning, the route round Cape Horn should be avoided on account of the great risk of the climate of the South Pacific Ocean and the chance of encountering icebergs, fogs, and un- favourable winds. Either the patient should come back round the Cape of Gooil Hope ; or it his strength permits he. may cross to California, travel overland to New York and thence by steamer; or, lastly, he may come by the Bed Sea, Suez Canal, and Mediterranean. The invalid must expect about 20 wet days on the voyage out. ' The temperatures met with range from 40° to 80° Fahr^ the coldest and most uncertain weather occurring in the North Atlantic and South Pacific Oceans. , Choice of Vessel. — The' following considera- tions may be useful in deciding between steam and sailing vessels : — For a steamer there is the greater certainty in predicting the length of the voyage, and the calms of the tropics are sooner passed. Against steamers, , there is the nuisance of steam and smoke on deck ; much space is taken up by the engines, stokers' rooms, &c., andhence other parts of the ship are more crowded ; the bilge water is tainted with the engine grease; there is the wearying grind of the screw by day and by night; while more seas are shipped, because a steamer can run against a head-wind. For sailing vessels there are the advantages of more room, Ught, and air in the cabins, and the absence of the above-mentioned disagreeable conditions. Against them there is the longer and more uncertain duration of the voyage, and the necessity of shaping their course by the prevail- ing winds. A word must be added as to the comparative merits of wooden and iron vessels. Briefly stated, iron ships are cleaner, drier, freer from smell of bilge water, and hence healthier than wooden ; but on the other hand they are less equable in temperature (hotter in hot and colder in cold latitudes), and less aerated by natural ventilation through their sides than the latter. They are also noisier. The vessel chosen should not be 'under 1,000 tons, and her age, class of passengers, the character, temper, and standing of her captain, as well as the size of her cabins, should be care- fully ascertained. Of course it is a w'ms qvA non that she should carry a duly qualified surgeon. The cabin for the outward voyage to Avistralia should be on the port side, so as to get the breeze in hot weather, and vice versd in returning. The cabin outfit should include a spring mattress, with hair (not wool) mattress over, a folding easy chair, chest of drawers, carpet, curtains, and sponge bath (Faber). Clothes of various degrees of thickness are essential, both for body and head, and a waterproof suit is necessary for bad weather. Plenty of linen must be taken, as washing is difficult on board, and there should be a supply of preserved milk, meat or essence of meat, fruit, and light wines. The iadicatiotis for a sea voyage are hereditary tendency to phthisis, or the presence of actual but uncomplicated disease in a very early stage, in persons not past middle life, with a fair digestion, absence of severe pyrexia, and general health not much impaired. Patients with a tendency to haemoptysis should not be sent, nor should those of a desponding disposition, who would thus be likely to suffer by the long absence from home, or from fears of their per- sonal safety. Of course a tendency to protracted sea-sickness is a distinct contra-indication. The invalid should be careful not to overtax his digestion too much ; he should take regular daily exercise on deck to the extent of his strength, have some definite occupation to beguile the time, and, if possible, be accompanied by a personal friend (Faber). Choice of a Climati'— General Hints. — It is a good plan, if possible, to order a patient a climate with that mean temperature and relative Jjumidity which he- is known to tolerate well (Sigmund). The patient's disposition must be considered,' and a lively or a quiet place chosen according to his temperament. We should not send a poor man to a place beyond his means, otherwise he has to grudge himself many com- forts, and loses much, if not all, the benefit of the diange. ' In sondingpatients to tlie South of Europe tills rule is too often neglected. The special indications for the climates of par- ticular places can only be understood by study- ing their local aspect. Generally r blankets. The sheet as it becomes heated may bo changed for one fresh and cold, or very (sold, water may be squeezed from a sponge over the sheet as the patient lies rolled up in it on a waterproof cloth. In scarlet fever of malignant type, where the rash does not readily appear, this form of cooling pack has been found most valuahle. Srs. Hillier and Gee h.ave both added their testimony to its utility. In Dr. Gee's cases the patient remained packed in the wet sheet for one hour and was then rpmoved to bed. The cases best suited for treatment by the wet pack are those where the skin is very dry and hot, and the patient exceedingly restless and delirious. 2. Gold Compresses, Irrigations, Iiotions, and Injections, — Cold may be coqtinuously ap- plied with a view to abating undue heat of a part of the body. Thus iced-water raps or compresses may be placed over an inflamed throat, or on 18 the head in inflammation of the brain. In acute pneumonia Niemeyer has commended strongly the use of cloths dipped in cold water, well wrung, and then applied so as to cover the chcstand es- pecially the affected side. These compresses are repeated every five minutes. Pain and dyspnoea are much relieved ; sometimes the temperature falls an entire degree ; and if the cold appliance* do not arrest the actual attack of pneumonia, they shorten its duration and promote speedy con- valescence. The necessity of bo often having to change the compress, and thus disturb the patient, is a great objection to this mode of apply- ing cold. A powerful sedative and antiphlogistic effect of cold can be obtained by irrigation ; i.e. allow- ing cold wafer to fall drop by drop on a doth, so as to keep it continually wet with fresh supplies of water. This may be done by sus- pending over the part to be irrigated a bottle of water, in which a few pieces of ice may be put ; one end of a skein of cotton, well wetted, is then allowed to hang in the water, while the other end is brought over the side of the bottle. This, acting as a syphon, causes a continual drop- ping upon the part to be irrigated. In injuries of joints, where it is of much consequence to cheek inflammation, this process, which abstracts heat gradually, and without disturbance of the part, is most valuable. Irrigation of the shaven scalp in cases of meningitis is a very powerful, cooling, and sedative appliance, requiring care and watchfulness. A cap of india-rubber over the head and back of neck, so arranged that :. current of cooled water may flow continuously through it, will act as a general reducer of tem- perature. Where pounded ice is applied to the head in a bladder, this should be suspended by a string from the bedstead, so that the head of the patient may not have to sustain the weight of the bag and its contents. Five ounces of sal ammoniac and five ounces of nitre in a pint of water will form a frigorific mixture, which can be applied in a bladder when ice is not at hand. The ice- bag, and cold water compresses renewed every three minutes, have been used as an appliance to strangulated hernia, and' to prolapsed rectum, to reduce the volume of the part and so facili- tate reduction. Care must be taken that the cold application be not continued so long as to cause gangrene. Cold wet compresses should not be applied over dry bandages, with which wounded or broken parts are secured. Several cases are recorded where a hand or arm has become gangrenous, in consequence of having been bound up with dry bandages, and then treated with cold water compresses. The dry bandages, as they become wet, contract tightly on the limb, thus stopping circulation and causing gangrene. A mixture made of spirit of wine and water, or of eau de cologne with water, js a simple form of cooling lotion. The spirit evaporates and so carries off heat from the surface. 1 oz. of rectified spirit to 16 of water makes a good spirit lotion, and the addition of 4 drachms of nitrate of potash, or chloride of ammonium, will add to its cooling and sedative effect. 4 drachms of the chloride of ammonium withialf an ounce of diluted acetic acid, and the same 274 COLD, THEEAI'EUTICS OF. quantity of rectified spirit in Ifi ozs. of camphor water, is another form for a very serviceable lotion. These lotions,/ applied by means of a piece of soft rug or lint over the skin, act as refrigerants, cooling the head when it is hot or painful ; reducing heat and arterial excite- ment in tumours or contusions ; and tending in the latter to promote the absorption of effused blood. Cold water, and cold lotifins of vinegar and water, are familiar means for trying to stop haemorrhage. In cases of severe uterine hsemori-hage, injee- tionsoi ice-cold water into the vagina, or into the rectum, frequently succeed in checking the bleeding. In cases of bleeding internal piles an injection of cold water, after the action of the bowels, braces the parts and constringes the bleeding vessels. 3. Dry Cold. TTses of loe. — Heat may be con- tiniiously abstracted from an inflamed part in a safe way, and without undue risk, by applying dry cold by means of a waterproof bag of vulcanised india-rubber filled with ice, snow, or a freezing mixture made of equal parts of salt, nitrate of potash, and chloride of ammonium. Moisture from the air will condense on the exterior of the cold bag, but a piece of lint interposed will protect the skin from damp. The india-rubber is a bad conductor, and too great abstrac- tion of heat need not be feared. The walls of an animal bladder conduct heat much better than the india-rubber, and it is necessary to watch carefully over the application of ice-blad- ders,' for whSn continuously applied they have been known to cause Severe frost-bite of the part. If, when cold is being applied, the patient persists in complaining of severe pain, it is right carefully to examine and see how the part is affected by the cold. Professor Esmarch, in cases of fracture, and in various forms of trau- matic inflammation, has applied ice for periods of twenty or thirty days with the best results. In cases of commencing disease of the vertebrae this surgeon has used cold water placed in a tin vessel, so made as to adapt itself to the part to be treated. Minor cases of bruise with inflam- mation may be treated by cold employed in' the form of a common bottle filled with cold water and kept pressed against the part. After opera- tions upon the eye, the extraction of cataract for example, a small ice-bag is very useful in reliev- ing pain and keeping down inflammation. Ice-bags placed along the course of the spine have been found effectual remedies in many forms of nervous disorder. In cases of epilepsy, where the circulation is sluggish, the hands and feet being always clammy and cold, an india-rubber bag of ice applied along the spine has been found to restore warmth, at the same time relieving headache and symptoms of incipient paralysis. Cold to the spinS is asserted by Dr. Chapman to lessen the excito-motor power of the cord. In the severe pain of an inflamed ovary or testicle ice in a bag may often be employed beneficially as an anodyne. Lumps of ice swallowed are invaluable in arresting haemorrhage from the throat and stomach. In tonsillitis and diphtheria this same treatment tends to reduce iuflamtaatiori and cool the throat of the patient. Obstinate vomiting can COLIC, INTESTINAl.. often be checked by swallowing fragments of ice. 4. Cold, as an Antesthetio. — Dr. James Amott, in 1849, brought forward the use of a freezing mixture of ice and salt as a means of producing local anaesthesia, by freezing the part to which thp mixture was appliedj either in a bag or in a metallic spoon. For sbaall superficial opera- tions this method of anaesthesia by congela- tion answers very well. The part becomes whit^e and hardened to the out of the surgeon's knifcj there is very little haemorrhage, and the wound made usually heals well by primary adhesion. ' More recently, Dr. Bichardson has indicated a very convenient way of inducing local anaes- thesia, by the volatilization of etherin the ^orm of spray, by means of the hand^ball spray atomi- zer. Ether Spia.yed on the bulb of a thermometer, held about an inch from the jet, bronght down the mfercury to within 10° Fahr. of zero. When the jet was turned on to the skin, a marked degree of local anaesthesia was produced, but not enough for surgical purposes., By driving over the ether under atmospheric prea- sui-e, instead of • trusting simply to capillary action — or to suction, as in Siegle's apparatiis'- one may bring the thermometer within thirty seconds to 4° below zero. By the use of this apparatus, at any season or temperature, the surgeon can produce cold even 6° below zero; and by directing the spray upon a half -inch iest- tube containing water, he can produce a column of ice iq two minutes; For local anaesthesia by cold, the ether spray anwers well. Such opera tions as the removal of small tumours, opening abscessed, and inserting sutures, may be pain- lessly 3)erformed. John C. ThorowgooB. COIiIC ((caXov, the large intestine). — Origin- ally colicsignified a painful affection due to spasm of the bowel, but though still retaining this ap- plication, it has now come to be further associated with other complaints which are attended with severe pain of a spasmodic character, a qualiJ^ng adjective indicating the nature and seat of each particular form. Thus refial colie is applied to the group of symptoms due to the passage of a stone from the kidney to the bladder ; h^alii! colw to those accompanying the escape of a gall- stone. See Couc, Intestinal. COLIO, IlTTESTIlirAL.-^STNON.: Fr. Colique ; 6er. Die Kolijc, DBFiNiTiON.^Painful and irregular contrac- tion of the niuaeular fibres of the intestines, without fever. JEtioloby. — Fredisposing causes. — These in- clude the. nervous (as hysteria, hypochondriasis), lytaphatic, and bilious. temperaments) sedentary occupations ; the female sex; and the period of youth or adult age. Exdiing cames. — These may be gr'oiiped as follows : — ^^1. Irritation from lodg- ment of ,gas due to fermentation of undigtstw food and decomposition of faeces long retained within the larg? intestine ; from faeces, or intes- tinal concretions, undigested or partly discs'*^ food, sudi as pork, shell-fish, salt meats, unripe fruit or septic game; from cold drinks or ices; from excessive, or morbid secret'ionsi>speei»to bile; from gall-stones; orfrom worms— abundleot COLIC. INTESTINAL, round worms or coiled up tape-worms. 2. Morbid states of the bowel, including obstruction from intussusception, twisting, strangulation, &c. ; ulceration (typhoid, tubercular, dysenteric) ; in- flammation (enteritis, typhlitis, &e) _ 3. Beflex nervous disturbance, due to anxiety, fright, anger, M other emotional disorder ; to disease of the ovarias or uterus; to calculus (hepatic or renal); to dentition ; or to exposure, especially of the feet and abdomen, to cold. 4. Blood-poisoning, as firom lead, copper, gout, rheumatism. Symptoms.— The characteristic or essential gymptom of intestinal colic is pain in the abdo- men, without febrile disturbance. It usually be- gins, and is most severe, in the umbilical region, then spreads to other parts, or to the whole abdomen, and is apt to travel from one part to another. It is almost always relieved by firm pressure and by expulsion of flatus, and is par- Bxysmal incharacter, remitting, or exacerbating, or completely subsiding at intervals. The suffer- ing is usually severe, often agonising, and to relieve it the patient bends forwards, pressing the abdomen firmly with his hands or against some hard surface, or rolls about. As a rule the ab- domen is distended by flatus ; in leadcclic it is, however, firmly retracted towards the spine, and the movements of the inflated intestines affected by spasmodic contraction, producing loud bor- borygmi, may -frequently be seen and may be felt by the hand applied to the abdomen. The muscles of the abdominal wall and the bladder usually participate in the internal spasm : the abdomen becomes rigid or knotted, and the recti muscles become contracted into round balls, while frequently the navel is retracted; mictu- rition is.fi^equent or suppressed. Usually there is constipation, and the pain disappears when the bowels iire freely relieved ; sometimes, how- ever, it persists for a time. Constipation stands in a twofold relation to colic, either as cause or effect of the spasm. The countenance expresses great suffering, anxiety, and depression, and the features may be pinched. The surface of the body is cold, es- pecially the feet, and the pale skin is covered by a cold perspiration. The pulse is commonly of normal frequency, or is infrequent and feeblej The symptoms vary somewhat with the cause. When due to irritating ingesta the prominent symptoms are vomiting and diarrhoea, sometimes ending in catarrhal dysentery. In children ,the legs are drawn up upon the iabdomen, the bowels are often at first confined, and the evacuations greenish, offensive, and very acid, afterwards' becoming loose. In nervous and hypochondriacal siibjects,and especially females, severe pain in the intestines, resembling that of spasmodic colic, is apt to occur i^see ENTEaAxoiA). Flatulence plays a varying part in different cases; it is often a prominent symptom, and the ibrm of coUo thus characterised has been termed Colica flatu- lenta. Vomiting is generally in proportion to the eevereness oif spasm, and the degree of intestinal obstruction. Ddbation. — The duration of the attack varies greatly, from a few minutes to several days. The spasm usually ceases abruptly, leaving a feeling of COLLAPSE. 276 soreness in the abdomen, while theie is enjoyable relief from suffering. Colic, when violent or intractable, may terminate in enteritis, in peri- tonitis, and, especially in children, in intussuscep- tion. Diagnosis. — A pain moving from place to place, relieved by firm pressure and unattended by fever, separates colic from other affections, more particularly from those due to inflammation, in which pain is always aggravated by pressure. Distension with spasm of the stomach may be distinguished from a similar condition of the colon, by the pain occupying a higher position in the abdomen (at or around the ensiform cartilage instead of— as in colic — the umbilical or 'hypochondriac regions), and by the percus- sion note elicited being deeper-toned and more prolonged than that which is produced by » distended colon ; besides in colic the spasmodic contraction of the colon, producin'; borborygmi, maybe traced bythe hand, or may be even seen, and there is tenesmus. , It should be borne in mind that enteritis or peritonitis may follow colic, when the pulse, previously unaltered^ may become frequent, hard and small, or frequent and soft, and the seat of inflammation becomes tender. Peognosis. — Colic almost always ends in re- covery, preceded by free evacuation from the bowels. Unfavourable signs are those arising from inflammation or intestinal obstruction. Teeatment.^ — In the first place the setiological indications should be met. The irritating contents of the bowels should be dislodged by purgatives combined with sedatives, such as calomel (five or eight grains) or rhubarb (twenty grains) with opium (one grain), followed by repeated doses of some saline aperient, such as magnesise vel potassae sulph., with tinct. of hebbane or opium, and spirits of chloroform, until free action of the bowels is obtained. A suppository containing half a gyain each of hy- drochlorate of morphia and extract of belladonna, or a subcutaneous injection of morphia, may secure immediate relief from pain before aperients have time to act. Large warm enemata often relieve quickly. Other suitable measures are — the warm bath, friction with warm oil or stimulating liniments, hot-water fomentations,, steamed flannels, mustard or turpentine stupes, flannel bags containing hot chamomile flowers or heated sand, the stomach- warmer filled with hot water, large linseed and mustard poultice. The diet should be liquid. In the prophylactic treatment the diet should be strictly regulated, lodgment of irritating solids and gases within the bowels should be pre- vented {see Constipation ; FiECBS, Retention of; and Fiatousnce), and the abdomen and feet should be kept warm by a flannel roller or belt and thick woollen stockings. Gbobge Oliveb, COLIiAFSli. — Definition.— Collapse is a state of nervous prostration. When it is ex- treme, the vital functions are in a condition of partial, and sometimes nearly complete, abeyance. It may terminate in death, or be followed by gradual reaction and complete recovery. Collapse and shock have usually been classed together, but it is not accurate to do so. It is 276 COLLAPSE. true that the ganglionic centres of the medulla ohlongata are more or less profoundly involved in both, and that both .possess many symptoms in common, dependent upon the derangement of function of one or more of these centres. Some confusion is attributable to the fact that shock is a terra applied not only to a state or morbid condition, but to the cause -which most frequently produces that condition — a violent imprfssion or ' shock ' to the nervous centres. See Shock. Collapse arises from many different causes, shock being one, of -which collapse may be regarded as a final and extreme degree, and into -which it often imperceptibly passes. Col- lapse, on the other hand, may occur under con- ditions -where there has been no antecedent state of shock. Collapse presupposes previous nervous exhaustion, while shock may instantly appear in a healthy individual. JEtiologt. — Any severe injury, especially if attended by profuse and sudden haemorrhage, may terminate in collapse, such, for instance, as the rupture of one of the abdominal viscera, a penetrating -wound of the chest or abdomen, or a wound of the heart or of a large artery. Ex- tensive burns or scalds frequently give rise to typical collapse ; and severe and prolonged pain is capable of causing it. Eupture of the heart or of an internal aneurism, if the patient do not immediately die, causes extreme collapse. Cer- tain poisons, as tobacco and arsenic, wiU also produce this condition. It is the terminal stage of some diseases, as, for instance, of Asiatic cholera; severe drastic purgation al-so, or pro- longed vomiting, from wnatever cause, may occa- sion it. The pernicious malarious fevers and yellow fever often end in collapse. In the acute yelloTf atrophy of the liver symptoms of severe nervous disturbance, resulting in a species of col- lapse, sometimes suddenly supervene. Fysemia, septiciemia, prolonged narcosis, frequently ter- minate in collapse. Symptoms. — The severity of collapse depends on the nature of the cause' and the physicfd and mental vigour of the individual. It may vary from a moderate to an extreme degree. A moderate amount is seen in the course of fever and some other diseases, but this neither modifies the progress of the malady nor attracts the notice of the patient, causing chiefly peripheral coldness. From this trifling amount coUapse may pass to the most intense form, where the patient scarcely differs in out-ward semblance from a dead body. A superficial inspection will fail to detect the existence of the functions of respiration and cir- culation. Vitsility may be said to have renched its minimum. In well-marked collapse from severe injury or loss of blood the pulse at the wrist may bo almost or -wholly imperceptible, the heart's action scarcely audible, very rapid, fluttering, and irregular ; the surface of the body, the face especially, is deadly pale and cold, and the skin moist -with clammy sweat ; the respiration IS very feeble, slow, and irregular, accompanied by sighing or gasping inspirations at intervals ; the expression and character of the face are lost; the features are sunken and relaxed; the eye is duli, glassy, starmg, or languidly rolling about, and the _ conjunctiva perhaps insensible to the touch; the nostrils are dilated; the sensibility COLON, DISEASES OK. of the whole body is diminished; andthemns- cular debility is extreme. The patient lies on his back, without a trace of voluntary effort. If a hmb is lifted it falls back again as if dead. Yet the consciousness and senses may be almost nn- impaired ; if roused by repeated questions fHe sufferer -will with visible effort make a coherent though, probably, inadequate reply. , If relief be not given, the respiration maj become slower and slower till each one appears the last, when a sudden sigh shows that life is still present; finally, the pulse and heart's ac- tion become more and more faint, and death results from pure asthenia. A condition closely resembling traumatic coUapse is often wit- nessed in the last stage of cholera, when in an extreme degree the patient almost resembles a corpse save for the convulsive motions indnced from time to time by the painful cramps. The surface is pale or bluish, covered with profuse sweat, but is at the same time cold to the touch. The hands and extremities are icy cold, the tongue is cold, and so also is the breath, whi'ch is gasping and paroxysmal ; no pulse can be felt at the wrist ; the eyes and features are sunlten ; the mind is apathetic, but nevertheless the con- sciousness may be perfect, and the patient ablg to respqnd to questions with a strong voice. Severe purging and tobacco-poisoning produce a condition extremely like that described m traumatic collapse. Some cases of malignant fever terminate in collapse, which is characterised by extreme anxiety, pallor or lividity of the face and surface, coldness of the skin, sweating, and a small, frequent, and irregular pulse. A decrease of animal heat, especially in the external parts, is characteristic of collapse. The temperature of the internal organs varies ; and there may be collapse with high intemaj tem- perature. This occurs in cholera, intense fevers, and some forms of septicsemia ; or the converse may obtain, as is frequently witnessed in the collapse of dissolution. Collapse; from loss of blood differs from syncope, although the latter may be described as an acute and transient form of collapse. In syncope the prominent symptom is loss of consciousness, which in collapse may be almost or quite perfect. For the pathology and treatSiekt of col- lapse see Shock. William MaoCoejiac. COIiIiAFSS, Pulmonary.— A condition in which the lung is simply more or less devoid of air. See Lung, Collapse of. COLLIQUATIVE {colligueq, I melt).— A term which originated in the belief that in cer- tain conditions the solid parts melted away, and were carried off as liquid discharges. The word is now generally applied to the copious sweats and diarrhoea which occur in certain wasting diseases, such as phthisis. COLLOID {niWa, glufe, and elSos, like).— A peculiar morbid product resembling in its characters glue or jelly, and found associated with cancer and other forms of new-groi-th. See Cancbb and SEaEMEBATioN'. COLOHr, Diseases of. — The colon partici- pates to a varying extent in the lesions and COLON, DISEASES OB. flerangements of dysentery, typhoid fe-rer, ente- ritis, peritimitis, and other affections. The special disorders to which it is most liable are inti- mately connected with its anatomical and phy- siological peculiarities. The colon is a distensible membranous tube, of large capacity, with chiefly solid contents, which are jjropelled slowly on- wards by the muscular contractions of the walla. The moving force and the resistance offered to it are often too finely balanced, so that whenever the energy of the former is somewhat reduced, an accumulation of excretory products is apt to be determined. Hence arise retention of faeces and gases, constipation and consecutive evils, suCh as colic, colo-enteritis, or ulceration of the colon. I. Atony. — Definition. — Loss of contrac- tility of the walls of the colon, leading to accu- mulations and other eequelse. Etiology. — The causes of torpor or atony of the colon are mainly those of constipation- sedentariness, indolent and luxurious habits, a sluggish and lymphatic temperament, old age, and general debility or exhaustion, as after a long and tedious illness. Whenever the walla of tiie colon are distended by solid or gaseous accumulations, the contractile power is apt to be enfeebled, leading to further retention and loss of tone. Atony of the colon is an essential element in the pathogeny of constipatiou not depending on mechanical obstruction. Tympanitic distension of the coloni from paralysis of the sympathetic nerve occurs in peritonitis and ' in feverjs, e.g. typhus fever. Symptoms/ — Torpor of the colon may be indi- cated only by constipation. There are usually the ordinary signs of retention of flatus or faeces. lu hysteria, and in inflammation of the bowels or peritoneum, flatus is apt to accumulate rapidly, and to produce great distension of the colon. Fteces may collect and form large tumours in any part of the large intestines, but especially m the caecum and sigmoid flexute. ]<'aecal and gaseous accumulations in the colon resulting from atony may produce the follow- ing effects, directly or remotely connected with them: — (a.) Local. — 1, Colic. 2, Inflammation of the wails of the colon, or of the mucous and sub- mucous coats, and ulceration. 3, Disturbances from pressure: thus flatulent distension, and large faecal accumulation encroaching on the cavity of the thorax and impeding the descent of the diaphrngm, may cause dyspnoea or short and rapid respiration, palpitation aud irregular action of the heart, with remote effects arising from a dis- turbed circulation in the brain, such as giddiness and headache; a distended caecum or sigmoid flexure pressing on veins and nerves may induce oedema, numbness, and cramps of the right or left lower extreniity. 4, Retarded digestion, de- rangement of the stomach and liver, and intes- tinal obstruction. (4.) General, — The .absorption of; excremen- titious matter is said, to lead to wide-spread general effects, such as a sallow, earthy, or dirty eomplexion, lassitude, debility,, offensive breath, loaded urine, &c. 1 RBATMENT. — Atony of the colon is usually a chronic disorder demanding prolonged treatment. COLON, DISEASES OF. 277 The hygienic and dietetic rules laid down in the article Constipation require in most cases to be supplemented by medicines. The most satisfac- tory results follow a course of tonics, combined with aperients, such as iron, quinine, strychnia, belladonna, with aloes, colocy nth, or rhubarb. The purgative should be adjusted to each case, so as to secure no more and no less than a regular and eflScient evacuntion ; and while the loaded colon continues to be thus relieved, the dose should be very gradually reduced. This tonic-aperient course may be greatly aided by local stimulation of the colon, as by fric- tion, kneading, electricity, cold-water compresses, or douches. The abdomen should be supported by a belt or roller. Bretonneau and Trousseau strongly advised a course of bellrtdonna, giving gr.^ of the extract or of the powdered leaf as a pill in the early morning, — the stomach being empty, — then two such pills if in four or five days the bowels do not respond, and increasing the dose, but not beyond that contained in four or five pills,' in twenty-four hours. A teaspoonful of castor oil may be given t«'ice a week to aid this course of treatment. Flatulent distension of the colon in the elderly and in females at the' climacteric period is often grieatly relieved by the prolonged use of a pill containing compound assatbetida pill and nux vomica aftermeals. Elec- tricity is sometimes uaed with benefit. Tympanitic distension of the colon in perito- nitis and in fevers is best treated by free doses of opium. II. Inflammation. — Synon.: Colitis, colonitis, colo-enteritis; Fr. coUte; Ger. Eiitsundwng dea Sohleimhautes des Kohns. An inflammation with ulceration of the mucous membrane and submucous connective tissue of the polon, producing lesions undistingaishable from those of dysentery, has been pointed out by Copland and farkes. Colitis is said to be a non- specific local affection, commencing in the sub- mucous tissue, and subsequently attacking the mucous membrane with its glandular structures — the primary seat of dysenteric inflammation. As in dysentery the inflammation induces gangre- nous destruction and ulceration of the mucous membrane and' underlying cellular tissue. A catarrhal form of colitis is apt to occur in measles. ' It often happens that tjie morbillous catarrh of the intestines exhausts itself by attacking tha large intestine, producing, that special form of colitis characterised by tenesmus and glairy bloody stools.' ' Infiammatory diar- rhoea, particularly in children, often terminates similarly. Colitis arising from retained excreta may in- volve the entire wall of a circumscribed portion of the colon, commonly the ascending colon and sigmoid flexure, or may be confined to the mucous and submucous tissues. In inflammation of the caecum (typhlitis) the walls of the ascending colon are more or less implicated. In faecal retention the mucous follicles of the colon may become obstructed, and the distension r»"sulting therefrom may lead to inflammation and ulcera- tion. Irritation of the mucous lining of tho colon from the lodgment of faeces may extend to the lymphntic vessels and glands. The glan- ' Trons-seau, Clinique MedicaU. 278 COLON, DISEASES OF. dular enlai'getnent cannot, howeTer, usually be recognised during life. While the symptoms of tabes mesenterica may be traced to enlargement and obstruction of the mesenteric glands, set up by irritation of the intestinal tract, it is doubtful •whether such results can follow a similar cause limited to the colon only. Treatment. — The treatment of colitis consists in the local application of fomentations, poultices, opium enemata, or morphia suppositories ; and in the use of gentle laxatives, such as castor oil, combined -with sedatives, such as opium or hen- bane. The catarrhal form generally terminates in spontaneous recovery. Trousseau^ advises the use of albuminous injections, or of injectionscon- taining about half an ounce of water and nitrate of silver— from | to IJ grains, — or sulphate of copper or sulphate of zinc — from SJ to 4 j grains. HI. Displaeements. — The parts of the colon most liable to displacement are the transverse colon and sigmoid flexure — the former may de- scend as low as the pubes, and the latter may occupy any position between the left iliac region and the right side of the abdomen. Usually the meso-colon is elongated; there is adhesion between the displaced part and the new site; and, the longitudinal bands being elongated, the lociili are obliterated. Displacements are most apt to occur in those who have long suffered from constipation, retention of faeces, chronic dysentery, hernia, or from encysted or other tumours. They may lead to complete obstruc- tion, and cannot usually be recognised with cer- tainty during life. IV. Diverticula. — A loculus of the colon from repeated accumulation may become so distended as to form a lateral appendix. Such a diverti- culum when loaded with faeces may be felt through the abdominal wall as a distinct tumour, which may collapse when pressed between the fingers. George Outer. COIiOTIB-BI.IH'DlTESS. — A defect of vision, the subject of which is unable to distin- guish certain colours, See Vision, Disorders of. COMA (Ku/ia, deep sleep). — A condition of profound insensibility. See CoNsaoTiSNE.ss, Dis- orders of. COMA-VIGIL (K»f»«i insensibility, and v^l, wakeftil). DBFrarrioN. — A symptom, or set of symptoms, where continuous sleeplessness is associated with partial unconsciousness. Coma-vigil occurs towards the end of diseases in which the nervous system is involved either directly or indirectly, especially where sleep- lessness has been a symptom in the earlier part of the disease. Thus it frequently appearstowards the end of an attack of typhus or of delirium tre- mens, when these are about to terminate fatally. Symptoms.— The patient lies quiet with his eyes half-closed,inattentive to everything around, but not absolutely unconscious. If the eyelids are touched, they are closed, and perhaps the head is slowly turned away. The eyes have a dull, half-glazed look, and slowly follow any moving object near them. The pupils are neither much dilated nor contracted, and they COMEDONES. move under the influence of light, but very sing gishly. The mouth is generally somewhat open and dry, as are also the lips. The power of swallowing is much impaired ; if a small quan- tity of fluid be put into the moutb, an effort is made after a sjiort time to swallow it, and this effort ' is for a time successful ; but after ths symptoms have been present for sime time, tha effort is so feeble that no result follows. The patient lies mostly on the back; if turned on the side, he either remains as placed, or often slowly turns to the former position on the back. The limbs are occasionally moved a little, and il the hand or arm be raised, a slight resistance is offered. If the bladder or the rectum be emptied, there is slight consciousness of the act, as if a feeling of discomfort preceded it. The pulse is quick and weak. The respiration is weak, but otherwise normal. The symptoms continue unbroken throughout, nothing like natural sleep occurring. Diagnosis. — Coma-vigil is distinguished- from coma by the presence of a certain amount of consciousness, by the quick pulse, and by thii absence of stertorous breathing. It' is (fistin- guished from concussion of the brain by the pupil not being contracted, by the history of the case, and by the absence of coldness of the skin, and of any sign of shock. ; Prognosis. — The prognosis is unfavourable; coma-vigil is almost invariably a fetal symptom. It may last from a few hours to three or foil days ; from twenty-four to forty-eight houis being the most common duration. It may deepen into actual coma ; but more usually the symp- toms change but little, save that the pulse be- comes quicker and weaker, and the respiration more feeble, and death by asthenia then results. Pathology. — As being little but a symptomi coma-vigil has strictly speaking no pathology. It seems to coincide with the gradual suspension through exhaustion of the functions of the ner- vous centres ; the cerebral' hemispheres being nearly if not quite inactive, while the action of the rest of the centres is kept up weakly but continuously, till the little remaining nervous power is exhausted, when death ensues. It differs from coma, inasmuch as in the latter, the medulla oblongata is the only centre left acti ve,the functionsof the rest being entirely suspended. It differs from concussion, inasmuch as the symp- toms attending the temporary unconsciousness of the latter are more those of irritation than of pure suspension of function. B. Bbvjsbidge. COMEDONES {comedo,^ consume).— Synon. : Grubs. —This is the. name applied to the little cylinders of sebaceous and egi- thelial substance which are apt to accumubte in the follicles of the skin, and to appear pn the surface as small round black spots. When squeezed out they have the appearance of minute maggots or grubs with black heads, and thence have derived their name. They jnay occur in all parts of the body where sebaceous follicles exist, but are most common on the face, the nose, the neck and shoulders, the breast, and within the concha of the ears, in the latter, situa- tion often attaining a considerable size. The accumulation of this substance is due to want of COMEDONES, espuisory po-wer of the skin, and to the slight impediment which is afforded hy the aperture of the follicle to its exit j and -when squeezed out it is found to vary in colour, in figure, and in den- sity, according to the period of its detention. When recent, the comedones are soft and white, and modelled into an exact cylinde* by compres- sion through the mouth of the follicle! when impacted for a considerable time they acquire the yellow tint, the transparency and hardness of horn ; and assume a bulbous figure from the dilatation of the follicle below the constricted orifice of the epidermis ; and by their bulk they sometimes stretch tlie hair-follicle so far as to obliterate it completely. Besides their usual composition of sebaceous substance and epithelial cells, they frequently contain lanuginous hairs, and not rarely the entozoou foUiculoriim in its different phases of development. When they raise the pore into a minute pimple they have a similitude to acne punctata, and might be mis- taken for that affection; whilst the black spot on the summit of conical acne is due to a comedo. Tbbatment. — Comedones are generally asso- ciated with a weak state of the skin as well as of the individual ; they are most frequently met with in young persons in whom the powers: of the constitution are not yet established, and will be benefited by generous diet and tonic treat- ment. Locally, soap and water with plentiful friction and ablution will be found of great service; and, as an astringent to invigorate a debilitated skin, a lotion of perchloride of mer- cury, in emulsion of bitter almonds (two grains to an ounce)' and spirits of wine. Ebasmcts Wilson. COMPLICATIOIT {oon, vrith, and plico, I fold). — It is difficult to give a strict definition of what ought to be included under the term camplieation, but the word signifies the occur- rence during the course of a disease of some other affection, or of some symptom or group of symptoms not usually observed, by which its progress is therefore complicated, and not un- commonly more or leas seribusly modified. The difficulty lies, in determining what should be looked upon as essentially part of the original disease, and what as a mere accidental occur- rence. For instance, many regard the cardiac affections which so often arise during the pro- gress of acute rheumatism as a part of the complaint, others as complications. The same remark applies to the relationship of renal dis- ease to scarlatina, as well as to numerous other cases. Complications arise in different ways. They may, as just indicated, be considered as develop- ments of the original morbid condition, resulting from the same cause and being more or less allied ; or they' are independent and accidental, of which an illustration is, to be found in the association of ague with scurvy or dysentt-ry, or in the co-existenc^ of two or more nf the exanthemata. The most important class of complications, however, are these which follow ' the primary disease as more or less direct consequences. These may further be induced in various ways. Thus, for example, in febrile diseases secondary lesions are liable to arise as CONCRETION. 279 a result of changes in the blood ; a mechanical act, such as cough, may lead to complications in the course of phthisis and other pulmonary affections; cardiac diseases frequently bring about consecutive changes in other organs, by inducing obstruction of the venous circulation, or emboli may originate under certain conditions and produce their usual consequences. It is of great practical importance to be acquainted with the complications which are liable to bs met with in the various diseases, and especially in those which are of an acute nature, in order that measures may be taken to prevent them, and that they may be recognized and treated at the earliest possible period, if they should oceor. FjlEDBItICK T. KOBERTS. OOMPOTTWD GBATTtrLAB OOBPTTS- CLSS. — Formerly these microscopic objects were regarded as of inflammatory origin, and as affording poisJtive evidence of the occurrence of infiammation. Hence they were termed ' com- pound inflammation globules ' (Grluge.) Almost all pathologists now, however, recognize the fact that they are not products of an inflammatory process, but result either from the degenei:a- tion of pre-existing cells, in which protein and fatty granules accumulate, or, perhaps, from the aggregation of granules originally distinct, which are present in abundance in degenerating tissues. They may even be formed out of the cells of morbid products, such as cancer. These com- pound granular Corpusdes derive their name from the fact that they consist of a large number of minute granules aggregated together, and they either present a delicate cell-wall, or this cannot be detected. Occasionally there is an appearance of a nucleus in the centre. Fkbdbbick T. Egberts. COMFBBSS. — Folds of lint or other mate- rial, which are used for the purpose of producing presoure, or as a pad by which hot or cold water or medicinal agents may be applied tc the surface. In the latter case the compress may be rendered waterproof by being covered by a piece of gutt:v-percha tissue or mackintosh-cloth. Set Hydropathy. COMPBESSIBIiE. — A term implying com- paratively slight resistance, and applied specially to the pulse when it yields readily under the finger. See Pdlsb, The. OOMPBESSION of Brain. See Beai», Compression of. COMPBBSSION of Lung. Compression of. See LrNG, OONCBBTIOW (con, together, and cresco, I grow). — Synow. : Calculus ; Fr. Cmicrition, Cat- cut; Ger. Coneremeni. Definition. — An unorganised body, formed either in one of the natural cavities or canals, or in the substance of an organ, by the deposit of certain solid constituents of the fluids of the part. In the widest sense of the term, Concre^ tions comprehend Calculi. Enumeration and Classification. — The fol- lowing classified list includes the principal varieties Of concretions : — 1. In glandular strucito'es; lachrymal, Bali- 280 CONCRETION. vary, pancreatioi prostatic, seminal, urinary, hepatic, sebaceous, and mammary. 2. In the drmlatory system : cardiac, and renous [pMeho/iths). 3. In closed sacs : peritoneal, and articular. i. \aculs-de-sac : bronchial, pulmonai-y, nasal, tonsillar, laryngeal, gastric, intestinal, praeputial, Uterine, and vaginal. 5. In the substance of tissues and new forma- tions, especially in the neryous systemi — Cor- pora amylacea, 6. Variotis, such as the concretions on the teeth knoTTO as tartar. GrBNEEAL ChARACTEBS AND NuMBEB. — CoU- cretions are generally firm or even of stony hardness ; but they may be soft and friable. Their colour raries from white to black through shades of yellow and red. Concretions occur either singly or in groups ; and their shape and size, as well as the character of their surface, vary considerably with their niunber; single con- cretions being more frequently rounded, larger, and less smooth than multiple specimens, which often present facets and polished sm-faces. Many concretions are composed of concentric laminae. Composition. — The chief constituents of con- cretions are inorganic, that is, mineral salts, in a basis of organic matter. The bulk of the salts are carbonate and phosphate of lime and mag- nesia, with smaller quantities of alkaline com- pounds. The organic basis is composed of albuminous substances, mucus, cholesterin, and colouring matters. Mode of Fobmation. — Concretions are gene- rally derived from the solid constituents of vital lluids, whether physiological or pathological. In most instances the fluids are delayed in the natural passages by some abnormal obstruction or dilatation ; and under such circumstances a chronic inflammatory condition of the walls con- tributes greatly to the probability of mineral deposit. Most frequently — as in the formation of the salivary and biliary concretions — the fluid portions of the secretion escape by the natural outlet or are absorbed, while the solid constitu- ents are deposited ; the particles being either agglomerated around a nucleus, or deposited in centripetal layers upon the surface of the cavity. In other instances — intracardiac, peritoneal, and articular, a nucleus is furnished by a portion of fibrin, blood-clot, or growth, on which fresh deposits take place, while calcification proceeds in the interior. In a third series, examples of which are found in the alimentary canal, the basis of the concretion consists of foreign or indigestible matter, such as hair, inspissated fseces, and masses of magnesia. Effects akd Symptoms. — The functions of a part occupied by a concretion are generally more or less impaired ; the neighbouring tissues fre- quently atrophy; and inflammation and ulceration are common results, ending probably in the escape of the body. The concretion may be passed along a duct, and this process is generally attended with great pain ; but concretions may remain where formed without causing symptoms. Occasionally they are spontaneouslydisintegrated or disiolved. Tubatmbnt. — The treatment of concretions will CONGENITAL. be found discussed under the heads of thediseasog of the organs where they respectively occur. , J. MiTCHBli BSDOB. OOUOUSSIOir (coneutio, I shake together). This terra is used to indicate a condition induced by a more or less violent shaking or physical commotion of the general system, or of somo particular organ, whereby serious symptoms may be induced, but no definite lesion can be detected to account for them. The nerve-centres are the parts most liable to be thus aiiected, concussioi; of the brain or spinal cord being of considerable moment, giving rise to more or less complete abolition of their functions, though this-^ect is usually only temporary. See BBAiii,Haiid Spinal Cokd, Concussion of. General con- cussion of the body is highly important at the present day, in connexion with railway acci- dents, after which persons seem to bo uninjured, or only to be slightly shaken, but subsequently grave symptoms, associated with the nerroiu system, set in. See Bailwat AcciDENTSt Besslts of. Frederick T. Eobeets. COBTCTTSSIOW OF BBAIW, SPINE, &o. See Eraih ; and Spinal Cord, Diseasesof. CONDYLOMA (Lat).—DEFiNiTioir.— Ex- crescences often found about the anus and organs of generation in both sexes. The term has been applied to simple cutaneous growths as well aa to those of syphilitic origin ; but since these latter are altogether due to a constitutional taint, and require a dilFerent treatment, they will be described separately undei: the heading of Mucous Tubercles, whilst the term Coniy- loma will be restricted to non-specific growths. Symptoms. — Condylomata are generally situ- ated in the neighbourhood of the anus and genital organs ; and they result from the irritation produced by acrid vaginal or rectal discharges, or by the natural secretions in dirty persons. They consist in hypertrophy of the tegumentaiy tissues, and generally form smooth pendulons growths, but they may be flattened, irregular, and ulcerated on the surface. They are vascu- lar, liable to become inflamed and painful from friction, and, as their position favours develop- ment, they may attain considerable size. Treatment. — When all inflammation has been allayed, these excrescences should bo removed with a pair of scissors; and to prevent their re- currence thorough cleanliness must be practised, and any discharge from the rectum or vagina stopped. If the parts be damp and perspiring they should be kept dry, and frequently dusted with zinc or bismuth powder, or bathed with seme astringent lotion. No general treatment is of the slightest service. George G. Gasooyin. COTTFLTTEITT (con^jw, I run together).— Applied chiefly to a variety of smallpox and of other exanthemata, in which the eruptiohruns together or coalesces. CONGEWITAIi (eon, togethWv and gm^Vt, begoiten). — Existing at birth: a term generally applied to diseases or malformations, such "M Congenital Syphilis, and Congenital CliAfooti ' CONGESTION. CONGESTIOH' (c&ngero, I accumulate). — Oyerfulness of vessels caused by accumulation of their contents: generally applied to blood-vessels. Ses CiKCULATiON, Disorders of. COWITTM, Poisoning by. See Appendix. COITJTTM'CTIVITIS.— Inflammation of the conjunctiva. See Eyb and its Appkndasbs, Dis- eases of. CONSOIOirSIirBSS, Disorders of.— The disorders of consciousness are so numerous as to malce it desirable briefly to consider them in one article, \rith a view to their classification and the better comprehension of their mutual relations. We shall, therefore, here group and arrange the various morbid conscious states, not aiming to produce a strictly scientific classification so much as one which will be practically useful. 1. Exaltation of. — Under this head may be ranged certain states of consciousness more or less distinctly bordering upon the un- natural, to be tnet with in persons under the influence of ' mental excitement ' from various causes, as from sudden good news, or generally pleasant surroundings ; also from a slight degree of poisoning by alcohol, opium, hashish, or other drugs ; or from an early stage of some forms of insanity, or of delirium. In this state of mental exaltation the individual's powers of perception, apprehension recollection, thought, emotion, and volition, would seem to be all more or less intensified, just as in that of hebetude or dementia they are diminished and conscious- ness is proportionately dwarfed. 2. Ferversions of.— Many of the various, defects here to be referred ♦o are very par- tial in the extent to which they implicate consciousness, though others are general. In what is known as an illusion some object of sense is not correctly perceived; or, in other words, some sensorial impression is quite wrongly interpreted, as when a feverish or a maniacal patient, looking at some inanimate object, de- clares that it is a cat or a dogabout to fly at him, or hearing even the slightest noise in any part of his room, interprets it to be the voice of some friend or imagined enemy. In the case of an hallucination, howeiver, forms are declared to be seen, or_ voices heard (by a patient suffering from delirium tremens, for instance), where no appreciable external realities could have started the notion. And in these cases, it is not that the patient sees or hears without believing ; he_ finpli^itly believes that the visions or Voices which have been conjured up subjectively by the working of his own brain, have a real existence in tlie outside world. It is necessary to m-ake this distinction because it is by ho means uncommon in regard to the olfactory sense (especially in some epileptics), for odours or smells to be perceived which the patient soon comes to know are purely subjective or devoid of any external correlative. Hallucinations and illusions, though occasion- ally existing alone, are quite commonly asso eiated with a very important and more general deran^ment of consciousness, viz., delirium. Ibis' IS a symptom very common in' many CONSCIOUSNESS, DISOEDEES OF. 281 fevers, in certain low states of the system, after severe frights, in inflammatory or other lesions of the brain and its membranes, as a result of some narcotico-irritant poison, or occasion- ally in a person who is recovering ftrom an epileptic attack, or from the stupor sequential to a series of convulsive attacks. The state itself varies much in intensity. Three fkirly distinct types exist. In (a) low or muiterinff delirium the patient lies still and more or less heedless of what is occurring around; or if heeding at all, the impressions which he receives give rise to erroneous perceptions (illusions) which are woven into tl^e incoherent fabric of his rambling thought. In (A) dtlirium tremens the patient is more restless, tremors of the limbs and of the muscles of the face are often easily induced, hallucinations of sight and hearing are common, and the character of the delirium reveals that the patient is, to an un* usual extent, possessed by fears, terrors, and other emotions of a depressing type. In (c) mid or raving delirium we have to do with a much more active state. The patient raves loudly and incoherently, more in regard to his fleeting dream-like thoughts than in connection with external impressions, of which he is more or less heedless. He is often violent in de- meanour, and difficult to be restrained, persons in this state being capable of great and pro- longed muscular exertion. The bodily activity accompanying this form of delirium is, in fact, just as characteristic as the great intensity of the mental processes. It is met with occasion- ally in some fevers, but more commonly in meningitis and in acute mania. In its early stages delirium is principally noticed during the transition-period between waking and sleeping— at times, that is, when the nervous system most needs the rainvigorating influence of sleep. It is in these cases,- too, that beef-tea or stimulants may for a time dispel all traces of the wandering thought. Whilst illu- sions and hallucinations enter largely into the mental activity of a delirious patient, delusions also are generally well-marked components. That is to say, the person becomes for a time possessed by an idea, notion, or fancy, for which there is' no real warranty, though he believes and wishes to act as though it were true. Somewhat allied to delirium in nature, though much lower in intensity as a menial process.is that incoherence of thought which is met with in many chronic maniacs, or in non-febrile patients suflfering- froni various organic brain-diseases. In its slighter degrees this incoherence displays itself as mere 'rambling' talk; the patient has not fufficient brainpower to follow up the main subject of thought, and is frequently di- verted into collateral channels. This, which is a natural state with some persons, may be dis- tinctly indicative of disease in others whose mental power has previously been of a more vigorous type. At times the incoherence is seen to be governed principally by mere verbal sug- gestion, the patient being led away from point to point in new directions, owing to the asso- ciations of some word which has been used bo- coming for the time dominant. This state ia often well seen in the sub-acute exacerbations of 282 CONSCIOUSNESS, chronic mania, though it may occur also where multiple softenings or indurations of the brain exist. At other times the incoherence is more ahsoliuter-wayward transitions from subject to subjeet, connected by no discoverable bond, ra- pidly following one another. The result in such a case is a mere unmeaning jumble of words, interspersed here and there with brief propo- sitions having a limited significance of their own, though often wholly unrelated to that which precedes or follows. Hypochondriasis is a perverted state of con- sciousness, having some resemblance to that of illusion, but in which ^ome internal or visceral state becomes the starting-point of impressions (possibly not actually painful) which, when mag- nified and perverted as they are in the mind of the patient, fill him with false and gloomy ap- prehensions of various kinds. This perversion of consciousness is more generalised than that which exists in the case of illusion ; and also instead of being a more or less temporary defect, it is one that may last for weeks, months, or even years. The state of mind of an hystErical patient is often not altogether different from tlrit of the hypochondriac. 3. Partial Loss of^Defects of this order are numerous and msiy exist in great variety. They may implicate almost equally nearly all the varieties of conscious mental aetivityj or some more tlian others. They may be either con- genital, or acquired during the life of the indi- vidual. '■ In idietcy we may have from birth defect in the power of concentrating the attention, a de- fective power of apprehension and of thinking, and a defective volition, shown alike by an in- ability to guide or control thought, and by a deficient vigour of bodily movement. Again, as a result of epilepsy, of organic braiu- dis^ease, or of injuries to the head, the patient may gradually lapse into such a condition from one of health, so as to become, as it is termed, ' demented.' Whilst this state of dementia may supervene at any age, it is much more common as a consequence of the brain-diseases frequent in advanced life. There is, moreover, a form known as seiiiie dementia, in which without any typical disease, but as a consequence of im- paired tissuervitality and diffused degenerative changes throughout the nervous syftem, the mental faculties undergo a more marked degra- datiou than is usually met with in old age. This condition in its minor degrees goes by the name of hebetude. In all such states or grades of idiotey and dementia, we meet with an undue tendency to sleep in the day-time as a result of the listless and languid mental condition. This is but another sign of ^ the general lowering of conscious vigour. Here we must include, also, a peculiar group of conditions, having some alliance to one ano- ther, and which are all characterised by loss of consciousness to some extent, either partial in range or general. They are — reverie, somnam^ bulism, ecstasy, coma-vigil, catalepsy, hypnotism., and trance. They are merely enumerated here, but are defined or described in their several places. In the latter of these conditions the loss of consciousness, in the ordinary acceptation of DISORDERS OF. the term (viz, loss of perceptive power) is eo absolute, that some may think it ought rather to be included in the next section. Loss oi per- ceptive power, however, would not seem to be absolutely synonymous with loss of conscious- ness. There is good reason to believe, for in- stance, that where the influence of chloroform and other anaesthetics is not pushed to the fullest extent, a condition of antesthesia intermediatu between slight and profound is produced, in which, whilst there is absolutely no conscious- ness for external impressions, so that pain is altogether unfelt, there is still a certain amount of cerebral activity— ^as evidenced by lajpbling and indistinct speech on subjects altogether apart from whftt the surgeon may be doing, , Then is mental' activity clearly, though the nature of this, as revealed by the patient's speech,, may preclude the notion that pain is at the tims being felt.' Sensorial consciousness, is. blattej out, whilst a kind of ideational consciousness remains. We have an,approximntio,nJx)suclia condition, also, in the case of sleep when, dreams are rife. But here sensorial consciousness is not completely in abeyance. Again, in certain rare and anomalous epileptiform attacks we may find the patients, after the first paroxysms, bereft of some senses, though not of others. They may hear what is said by those around them, though they continue for a time quite unable to see or i. Complete Iiossof. — Inveryprofojinflsteep (sopor), in that prolonged form of it in which the person, if he can be momentarily roused, drops off again immediately {lethargy)ya^i also in profound antesthesia, there is complete loss of consciousness. The terms sopor and lethargy are now rarely used, and authors are not even agreed as to the precise , state which should he designated by the latter word. In syncope we have insensibility resulting from a cutting off of the preper supply of blood to the brain ; whilst in aitphyxia we have a like result fallowing upon an interference with re- spiration. A condition of narcosis or profound insen- sibility may result from opium or other dmgs and poisons, amongst which alcohol is to be in- cluded as one, of the most common producers of such a state. Or it may also be due to th« deficient elimination of urinary products by the kidneys, when ursemic coma is produced. Complete loss of consciousness exists for some -time during the ordinary form of epilifiie i^t, or during an' attack of convulsions; though in other epileptiform fits, not unfrequently met with — having some of the characters of hyste- rical convulsions — there seems to be a loss of sensorial consciousness only (loss of percep- tion),, whilst a certain amount of ideational consciousness remains. In apoplexy also there may be for hours or days a more or less pro- found loss of consciousness. In the less pro- found attacks, as well as after an epileptic fit or an attack of convulsions, the loss of con- sciousness is not complete, and wo have a con- dition now commonly known as stupor, Tlii> state is also frequent .as a result of concussion or otljer injuries of the brain,.and, it, occasionally follows a severe fit of hysterical, conTnlsitW CONSCIOUSNESS. It may last for hours, days, or even creeks in some cases. In it the patient lies with his eyes closed, taking no heed of what is passing around, though he may show obTious signs of feeling when touched or pinched, and may be capable of being momentarily roused, so as to give a short monosyllabic answer, if slightly shaken or spoken to in a loud voice. On these occa- sions, signs of- impatience are often shown. Though such a patient will nob ask for fond, ho will often drink freely when it is offered. He win of his own accord, when his bladder is full, sometimes get out of bed, find the chamber- pot, use it, and return to bed without saying a word — and then speedily relapse into his previous state of stupor. When the insensibility is more profound, both urine and faeces are passed incon- tinently, The state just spoken of is referred to in this section because it is so intimately alliedto and connected hj all sorts of transition conditions with another, known as coma, in which the loss of consciousness is more complete and absolute. There are different degrees of stupor and there are different degi'ees of coma ; the former is commonly spoken of as slight or deep, whilst a comatose condition, coma, and profound coma (the latter being what the older writers termed cams) are the phrases ordinarily used to denote the increasing insensibility of the graver state, which is more especially characteristic of the apoplectic condition. Coma may result from long-continued exposure to eoldj from sun-stroke, from poisons of various kinds, &om erysipelas of th* head and fece, from inflammations of the meninges, ! multiple embolisms, the effects of hyperpyrexia, orfrom cerebral haemorrhage. The most common cause of very profound coma is cerebral haemorrhage (apoplexy)j In this condi- tion the breathing is eften loud and stertorous, and consciousness is entirely obliterated, so that there is an utter absence of reflex movements when a limb is pinched or when the conjunctiva is touched. The patient in the deeper forms of coma often cannot be roused at all, even for a moment, aDd if this state does not terminate in one way or another before the expiration of twenty-four hours, or if it does not gradually pass Jntb 'one of mere «tupor, a fatal result may be considered imminent. H. Chahltok Bastian. COITSTIPATIOIT (con, together, and siipo, Icram). — Dkfinition. — Infrequent or incomplete alvine evaeuatioHi leading to retention of faeces. iEnoLOGT. — The causes of constipation may be heal — an impediment to the onward movement of the faeces in the. large intestine or from the rectum! or jej)«ra/— pertaining to habits, (^et, and other conditions. Local. — These include :— :(ffl) Lesions inducing narrowing of some part of the large intestine^ (J) Collections oif scybala, intestinal concretions, &e. in the cseeura, sigmoid flexure, or rectum, (e) Pressure on the rectum, by uterine fibroid or ovarian tumours, uterine displacement, the gravid uterus, or an enlarged prostate, (rf) Defecation thwarted, as when the expiratory abdominal muscles are enfeebled, as in pregnancy, especi- ally when repeated or after twins, obesity, old CONSTIPATION. 28B age, or in some painAil affection of tlio abdomen, such as rheumatism of the abdominal walls and diaphragm, chronic dysentery, piles, anal fissure. (e) Feeble contraction of the intestinal muscular fibres, as in distension of the large intestine or a portion of it by gas, faeces, or lumbrici, in- flammatory affections, lead-poisoning, senile atrophy, or in delicate females with lax muscular fibre (see Colon, Diseases of). (/) Pain in the pelvic viscera and probably elsewher9 may induce paralysis of the sympathetic nerves sup- plied to the intestinal walls ; thus may be ex- plained obstinace constipation in painful uterine and ovarian diseases, which cannot be accounted for by pressure on the bowels or otherwise. General. — The general causes of constipation are:— (a) Sluggishness of function —lymphatic temperament, anaemia, especially with amenor- rhoea ; or disposition to great activity of the muscular and nervous system, (b) Certain habits, namely, sedentariness; too great muscular ac- tivity; mental application, especially when exces- sive or prolonged ; the continued use of aperients or enemata after the relief of temporary consti- pation ! habitual disregard of, or hurry ia the act of defecation ; prolonged hours of sleep ; the excessive or even moderate use of alcohol, tea, tobacco, or opiates, (c), Dietetic errors.-p-Diet too nutuitious^ leaving little intestinal residue — or poor and insufficient; improper feeding, especially in infants and children; the use of indigestible substances, such as cheese, . nuts, or cucumber. Constipation is frequently a prominent symp- tom in diseases of the stomach ; of the liver ; of the heart, inducing congestion of the portal system and of the nervous system : as well as in connexion with diabetes, excessive perspira- tion, prolonged lactation, and disehayrges. The causes of constipation are such as evi- dently induce one or both of the following con- ditions.— 1. Dryness and hardness of the contents of the laiige intestine from deficient secretion, or too active absorption of fluid from the intes- tinal tract. 2. Impaired contraction of the muscu- lar fibres of the large intestine. Desoeiption. — ^In constipation the evacuations are infrequent, solid, deficient in quantity, and sometimes unusually offensive ; they often consist of dry, hard, dark or clay-coloured masses or scybala. Defsecationisgenerally difBcultor even paijiful. As a rule the depth of colour, and the scybalous character of the motions, are i n propor- tion to the duration of the lodgment of faeces in the large intestine. Infrequency of defaeoatiou regarded alone is an untrustworthy sig^. of consti- pation, or constipation demanding medicinal or other treatment, inasmuch as it often depends on indiyidual peculiarity. Good health is consistent with wide departures from the ordinary rule a jlaily evacuation ; not unfrequently there is no relief from the bowels for several days or even for a week, and yet without inconvenience, so long as the infrpquent defaec^tioii is habitual, or can be ascribed to idiosyncrasy. The disturbances of function usually associ- ated with constipation may be local, or extend to distant parts. The immediate or local effects are such as may arise from retention of feces:— signs of fsecal 284 eoUections in the caeoam, colon, sigmoid flexure, or rectum ; irritation of portions of the intestine, indicated by colic, inflammation, ulceration, and perforation oi the intestines ; intestinal ob- struction ; pressure of faecal accumulations on the intra-pelvic vessels and nerves, inducing menorrhagia, uterine catarrh, seminal emissions, haemorrhoids, cold feet, neuralgia and numbn.>ss of the legs (Niemeyer). Constipation frequently exerts a pernicious' influence on primary diges- tion, indicated by foul tongue, foetid breath, anorexia, acidity, flatulence, biliary disturbance ■ — even jaundicej and urine loaded with lithates. The remote or general effects of constipation are lassitude of body and mind ; headache, flushing and heat of head, vertigo j anaemia and wasting. Teeatmbnt. — Constipation depending on in- dividual peculiarity is rarely relieved perma- nently by treatment. The bowels, having acquired from early life the habit of infrequent evacuation, may be stimulated for a tittie, and are then apt to become more sluggish than before. In all cases the habit of the patient in this respect from childhood should first be determined, either as a warning against active or prolonged treatment, which may prove in- jurious, or as a guide to the adjustment of direc- tions and remedies — affording as it does a limit which should not be over-stepped. 1 . JEtiological, Dietetic, and Hygienic Treatment. —In treatmg constipation the causes should be met. Local causes— such as those inducing con- traction of or pressure on some part of the large intestine, or feeble or ineffectual contraction of the intestinal muscular fibres or of the ex- piratory muscles, should first be eliminated. Habits disposing to constipation should also be corrected. Persons who are much preoccupied or careless 'are apt either to disregard the call to stool, or to perform the act of defaecation hurriedly, incompletely, and; at irregular intervals. The sensibility of the nerves of the reeium becomes blunted by the constant contact of faeces. Hence the periodical removal of collections in the lower part of the large intestine is an essential element of the treatment. It is best wLeu this can be done by well-timed natural efforts. The pa- tient should be told to attempt defaecation every day after breakfast, and to persevere in so doing even when the result is occasionally or frequently unsuccessful. While straining to relieve the bowels, he may facilitate evacuation by pressing firmly the fingers in front and on each side of the coccyx, thus supporting the levator ani during contraction. Failing to obtain relief on the second day, a small cold water enema should be used to prevent further accumulation of faeces in the rectum, and to restore tone and sensibility to the blunted nerves. The enema should never be larger than is required to dislodge the motion from the pouch of the rectum — nor should it be warm ; at first it may be tepid, afterwar. Is cold. When evacuation is obstructed by the lower part of the faecal mass becoming dry, relief may be obtained from emollient enemata and supposl- biries, such as infusion of linseed, decoction of marsh- mallow, solution of white of eggs, olive oil alone or in oatmeal gruel, or glycerine injected in Bmall quantity into the rectum, and allowed lONSTIPATION. to remain there for some hours ; or by the use of suppositories at bed-time, consisting, of cocoa- butter, soap, or honey hardened by heat, either alone or combined with a stimulant to excite the ' flow of mucus into the rectum, or with extract of belladonna or of stramonium. Seden- tary habits should be broken into. Exercise on foot or on horseback is specially toi be commended, and carriage exercise to be avoided. While studying or reading the patient should walk about, and stand rather than sit at the desk. Gymuasties and out-of-door games are useful when a. limited time only can be . de- voted to exercise. Excessive and exhausting exertion should be avoided. It is generally advisable to recommend early rising and cold bathing in the morning. In different cases one or other of the following may be found ser^ viceable : a shower- or sponge-bath contaimng vinegar, baysalt, or consisting of sea-water, or a cold sitz bath ; douches directed to the abdo- men ; a cold water compress applied to the ahdo- men during the day or night or for three or four hours in the morning ; friction or kneading is the course of the colon every momingand when at stool ; an abdominal belt (flannel oc elastic) -r-sspecially if the abdomen be pendulons. The in- terrupted current of electricity has been success- fully employed as a special exci tor of the muscular fibres of the intestines or of the abdominal vail. Diet. — Vegetable should predominate over animal food. Greens (cabbage^ lettuce,; &c,) are useful, as well as fruits, which should be ripe, and taken on an empty stomach. Prunes or figs stewed in olive oil, or infusion of eenna, prune- pulp, oils and fats, such as cod oil or dive oil, are also serviceable when they do not disturb the digestion. Bread made of brau{er three, parts fiour and one part coarse bean), of corn-meal, or of cracked wheat ; patmeal por- ridge ; or wheat ground in a coffeeTmiJl, boiled and salted and served like rice, only less thick, may assist in preventing constipation ; if there be acidity and other symptoms of dyspepsia, however, these indigestible articles of diet should be avoided. Tobacco-smoking after meals m moderation sometimes relieves constipation. Cold water or carbonic acid water — a tumblerful at bed-time, or preferably on rising in the morn- ing, may be useful. Much must be left to indi- vidual' experience; sometimes coffee, or beer, or cider answers best. As a rule farinacea, astnn gent wines, and tea increase constipation. 2. Medicinal Treatment, — When dietetic and hygienic directions fail, they require to be assisted by medicinal agents. The ends to be seemed are threefold : — 1. To evacuate faeces and gcsef whicH. d'stending the large intestine, thwart peri staltic action. 2. To tone the walla of thohowel. and thus prevent reaccumulation of faeces and the products of their decomposition. 3. To increase the flow of intestinal mucusi Kemedies are usually variously combined for these pur- poses, and should be carefully adjusted to the requirements of each case, so as to meet the leading indications. Among the most useful aperients are aloes or its watery extract; rhubarb, coloeynth, gamboge, and podophyllinj and eitb* of these may be variously coml^ined with extract of hygseyamus or belladonna, extract of gentian. CONSTIPATION, extract of nnx vomica, quinine, sulphate of iron, or Ipecacuanha. The dose of the aperient should not exceed that required to secure gentle evaouation, and it varies -with individuals. Purging exhausts torpid bowels, and perpetuates oonscipation. The bowels should not be puslied to more frequent relief than has been habitual with the patient from early life. The aperient, which should be varied in a prolonged course of treatment, should be very gradually dropped, while the intestinal tonics (belladonna, quinine, nux vomica, iron) are continued. The duration of treatment is prolonged until the aperient is almost entirely withdrawn. The remedies should be taken immediately or two or three hours after the principal meal. The treatment by bella- donna, introduced by Bretonneau, was greatly prized by Trousseau {see Colon, Diseases of). In anaemic subjects a firm and prolonged course of iion should be aided by aloes, nux vomica, and arsenic. In hsemorrhoidal complications aloes should as a rule be avoided, and laxative electuaries should be prescribed ; in some cases, however, it tones without irritating the rectum. Flatulent dyspepsia and tympanites are indica- tions for the prescription of nux vomica, which, however, will not radically cure constipation. In obstinate cases the most useful remedies are colocynth — tincture (Prussian Pharm.) 5 minims or more on sugar or in water throe or four times a day, or 10 to 2U minims an hour before breakfast ; extract or compound pill with small doses of croton oil, or with gamboge, elaterinm, or other combinations ; podophyllin with bella- donna (Trousseau), ipecacuanha, and colocynth or aloes. A full dose of opium may liberate the bowels after the failure of the strongest purgatives, and constipation depending on inhibi- tion of the sympathetic nerve from pain, will be relieved by opium with belladonna. Enemata, when frequently required, should be small in quantity, and at first tepid, then cold ; for occa- sional use for the purpose of clearing away faeces loading the large bowel, they should be large (from two to six pints) and warm (see FaiCES, Retention of). The frequent use of large warm injections is injurious. Purgative waters, such as the Friedrichshall, Pullna, Huriyadi, or Carlsbad waters, given occasionally in small doses with warm water in the early morning, are often valuable adjuvants to a well-organised course of treatment. Constipation cannot, how- ever, be cured by a course of saline purgatives, and may be greatly aggravated by it. Numerous other drugs have been recommended in the treatment of habitual constipation, among which are nitric acid ; arsenic with food in de- bilitated ansemie females, in the sedentarj, or the old; tincture of benzoin — 20 minims thrice daily; tincture of colchioum — a few drops after each meal ; carbonate of iron ; compound liquorice powder with sulphur — a teaspoonful at bedtime m water; tincture of veratrum viride — 3 minims four or five times a day ; or ox-gall dried, in pills. Geobob Ouvbb. OONSTITirTIOIf.— SiifOH. : Diathesis, Habit, Conformation of body Fr. Constitution ; Ger. Leibesbeschajjenheit. The constitution may be sound or imsound. CONSTITUTION. 285 A sound constitution may be defined as the harmonious development apd maintenance of the tissues and organs of which the body is made up. It originates with the union of a healthy sperm and germ cell, continues with the growth of the product under the most favour- able conditions to adult life, and becomes gradu- ally enfeebled with advancing age by the process of natural decay. The constitution may be unsound in con- sequence of deficient vitality This deficient vitality may be general, as is sometimes ob- served in the children of parents one or both of whom are in advanced life, or whose vitality on one side or the other has been reduced by excesses, such as alcoholic or venereal. Ex- hausted vitality from prolonged disease, e.g. phthisis or tertiary syphilis, aifpcting either parent, may determine the death of the offspring at an early period from mere failure of nutrition, or may cause it to succumb to acute disease not not necessarily associated with any inherited tendency of a special kind. The deficient vitality may be restricted to certain tissues or organs, viz., those concerned in the nervous, vascular, respi- ratory, or digestive systems. Thus amongst the most strikingly hereditary of diseases are those of degeneracy, such as emphysema, structural heart^iseases, atheromaof vessels, certain kldney- disensps, &c. Bightly interpreted, these diseases are of the nature of premature senility, attacking certain tissues or organs — as it may be seen to attack the hair or the cornea — from some in- herent defect in their vitality. The constitution may, in the second place, be unsound from some definite inherited form of disease. Although the constitution of an indi- vidual begins with his life, it is nevertheless the resultant of the constitutional peculiarities of many antecedents. This being so, tendencies to disease may date far back in the pedigree, to be called forth from time to time by &vouring cir- cumstances. We need, however, practically only go back a few generations in inquiring for those diseases whicli are well recognised as being hereditary. These form one section of the group of constitutional diseases. — Congenital syphilis, gout, sciophulosis, tuberculosis, cancer, asthma, and certain neuroses are all diseases which are apt to appear at certain periods of the life of the offspring, in consequence of some specific inherent defect of blood or tissue derived from his pro- genitors. The constitution may, thirdly, bfoome unsound at any period subsequent to birth, (a) This may be dne to the surrounding conditions of lifebeing evil. Deficient or impure air, insufficient or improper food, defective sunlight, over- work, intemperance, &e., may injure the constitution and give rise to diseases whoso constitutional nature is some- times strikingly shown-, in the tendency of some of them to become hereditary, Eickt-ts, phthisis, and scrofula are examples„(4) The introduction of certain poisons into the system affects the consti- tution profoundly, and in some cases permanently, after the more obvious effects of the poisons have passed away. All the acute specific zymotic dis- eases, including vaccinia, would come under this category. • They render tue organism, for a long period or for life, proof against subsequent 286 CONSTITUTION, ftttacks of the same disease. Only in certain cases, howeyep, can the soundness of the consti- tutiou be said to be impaired by such diseases, and then it is usually through the occurrence of sequelsB. E- 6ot;GiLAS Powell. OONSTITUTIOlfAIi DISEASES. — These, may be regarded as diseases generated from within, in the course of ttewear and tear, nutrition and waste of the body, in consequence of inherent or acquired weakness in its con- struction^ The applicability of the term 'constitutional*, to disease is sufficiently explained lin the pre- ceding remarks on 'constitution.' The term may, however, be associated with' a group of so-called 'general' diseases, in opposition to that which includes ' zymotic ' or ' specific' diseases, which are generated by the introduction of some definite poison from without. In our present state of knowledge, howerer, no very rigid lines can be drawn to separate local, general, constitutional, and specific diseases from one another. See Diseasb, Causes of. E. Douglas Powell. CONSTKICTION' {eonstringo, I bind to- gether). — A narrowing, to a limited extent, of a canal or hollow organ, due either to a textural change in its walls, or to the pressure of a band surrounding it. COITSTTMPTIOIT {donsumo, I waste). — This is a term for any wasting disease, but it is gener- ally applied to pulmonary phthisis. See Phthisis. COWTAGIOIT. — ^The word contagion is ap- plied in pathology to the property and process by which, in certain sorts of disease, the afifected body or part causes a disease like its own to arise in other bodies or other parts; and the Latin word contagitim is conveniently used to denote in each such case the specific material, shown or presumed, in which the infective power ultimately resides. See Ztme and Zymosis. The property of coNTAaiocsNESs belongs to a very large number of the diseases which aifeot the human body. And in more than this direct way the property is of great interest to mankind. Contagiousness of disease is a fact not only for man, but apparently for all living nature ; and' the influence of 'contagion in spreading destruc- tive diseases among domestic animals, and among those parts of the veiietahle kingdom which con- tribute to the nourishmfent of man, is such as to make it of immense social importance that the laws of contagion should be well studied and understood. Further, just as contagion in the' case of living bodies and their parts spreads disease from one to another, so, to an immense extent, in the' case of certain matters which, though of organic origin, are net living, it spreads various processes of decay; The So- called 'fermentations' which yield alcohol and vinegar, as well as that in which putre- faction consists, are contagious affections of the respective matters in which they occur : every cheesemonger knows that moulds of different kinds spread by inoculation, ■ each in its own kind, from cheese to cheese ; and if the Greek proverb 'grape mellows to grape' is true of the- CONTAGION. living frait, the apple-loft gives analogous ex. periences of contagion among the fruit which is garnered. The EATioNALE of the word ' contagion,' as now used, is that the property is understood to attach itself essentially to a material coniaot; not neceii- sarily that, when infectioii is spread from indi- vidual to individual, the contact of the individuals must have been imtnediate ; but that'in all oiMf there must have been such passage of material from the one to the other, as was in itself at least a mediate contact between them. And similarly, in those very instructive illustrations of the process of contagion which are furnished within the limits of a single diseased bod.v by the propagations of disease from part to part of it, we can in general easily see that infection advances from part to part, either in proportion as part touches part. Or in proportion as the one receives from the other the outflow of lymph or blood or secretion. The various specific matters which effect con- tagion in the living body, the respective ' con- tagia ' of the given diseased, seem all to have in common this one characteristic : that rn ifptb- I priate media (among which must evidently be counted any living bodily texture or fluid which they can infect) they show themselves capable of sel/-miUiiplication ; and it is in virtue of this property that, although at the moment of their entering the body they in general do not attract notice, either as objects of sense or as causes of bodily change, they gradually get to be re- cognisable in both of these respects. Now, the faculty of self-multiplication is eminently one of the characters which we call vital ; and when it is said that all contagia are self-miiltiplyiiig , things, this isatleastverystronglytOsuggestthat perhaps all contagia are things endowed with life. In order to any general consideration of the ' question thus suggested, contagia may_ conveni- ently (even if but provisionally) be distinguished as of two main classes, differing, or at present seeming to differ, from each othei: in their mode of action on the organisms which they infect: one classj namely, that of Parasites; and' the other class, that of the true or Metabolic Con- tagia. Of this separation, so far as present knowledge seems to justify it, the assumed grounds are: that each true Contagium; in proportion as it m'ultiplies in the body, tram- farms, in a way which is specific to itself and is different from the ways of other contagia, the bodily material with which it has contact; while, on the contrary, the Parasite, however much it may grow or multiply in the body, produces no qnalitative effects specific to itself, but only such effects as are of common kind to it and all other parasites — ^indications; namely, of its medtmiad intnmveness in the parts which it occupies; and sometimes of the drain -which it makes on its host's general nutritive resources. A. — Of Parasites, in relation to processes of contagion, little needs be said in the present article. When an organism or part of it is, in greater or less amount, inhabited by other organisms, animal or vegetable, which subsist on it, or its food or refuse; it of course may be a centre of infection to other (if susceptible) bodies or parts, to which it can transmit live CONTAGION. 287 t hi paraaites or their germs or seeds : for, when this transmission takes place, growth and self- multiplication, as in a colony, are the natural results which have to be expected ; and in pro- portion as these occur, the newly-infected body or part gradually gets to suffer, like the old, from those particular derangements which make the type of parasitic disease. Some parasitic diseases, especially some of those of the skin, spread actively by direct conta^on in ordinary inter- eonrse ; as for instance, scabies by the migration of its acari, and porrigo (among children) by the spores of its microphyte; and the spreading of such diseases where they exist may of course be to any extent facilitated by aggregation of per- sons and nncleanliness of personal habits. There are cases in which parasitic disease spreads from animal to animal only in proportipn as the one feeds on the other, and eats it with para- sites still living in it ; or in proportion as live parasite-eggs or larvse, discharged &om the body of one animal, get conveyed with food (especi- ally on raw herbage and in water) into the bowels of another. Considerable epidemics of trichiniasis in the human subject have been traced, chiefly in Germany, to infection from the ^g; in cases where pork, abounding with trichinee, as been eaten, as sausage-meat or otherwise, in a raw or imperfectly-cooked state : and in Iceland the very great sufferings of the human subject and the cattle from echinococcus have been traced to the influence of the dogs in spreading contagion from the slaughter-house, where they eat hydatidised offal, to ^e kitchen-ganlens and water-sources and pastures, where they dis- charge tape-worm eggs from their bowels. See PoBRiQO, Scabies, Trichina, Hydatid, &c. The diseased states which consist in being colonised by parasites are diseases of indefi- nite duration, tending in some cases to indefi- nite increase. In cases Where the disease consists in the presence of swarms of blood'sncking or otherwise exhausting animal parasites, symptoms of the blood-drain will of course gradually arise ; but otherwise the parasite, whether animal or vegetable, operates only as a mechanical presence. Skin and mucous membrane will be irritated in their superficial layers, and in some cases more deeply, by the animal or vegetable parasites which breed on or in them, just as they might be by dead mechanical irritants : solid organs haying cystic entozoa in them will in like manner show evidence of irritation by encapsulating the colo- nists; and the sun;ounding tissue will of course suffer'cbmpression and displacement in proportion as the colonisation (e.g; in ease of echinococcus) iscomj^actandmassive. In the case of trichiniasis — but, in our ordinary experience, in no other — the multiplication of the parasites, the burrowing of their young, and the general diffusion of these in the body, are processes of such extreme activity that, if the quantity of contagium taken into the stomach has been large, the innumerable local irritations suffice to make a very acute fever; but even in this extreme caeb, the merely irrita- tive type, though exaggerated, is essentially pre- Beived. As different sorts of animals are notoriously liable to different sorts of parasites, so, even among animals of one sort, as for instance in the human kind, the liabilitt of different bodies to receive particular parasite-infections, does not seem to be quite equal for all. Especially, the vegetable parasites seem to have their affinitie° determined or modified by the general state of health of the recipient; and there are cases in which it looks as if there ran in particular family- lines (perhaps with some slight chemical idiosyn- crasy) a special liability tO' particular intestinal worms. There, however, is no reason to believe that in regard of the more important animal parasites, as particularly of trichina and thetaani- adae, the susceptibility of individuals to attacks is other than universal and practically eqtial. B. — The true or metabolic contagia (to which the rest of the present, article will exclusively refer) — the contagia which, in their respective and specific ways, operate transforming ly on the live bodily material which they affect, are perhaps the most important of all the inciden- tal physical influences which concern mankind. Whether they may all, at some time hereafter, admit of being named, like the parasitic con- tagia, in terms of biological classification, is a question which needs not in the first instance be raised ; for meanwhile the identity of each separate true contagium is settled ia experimental and clinical observation by the uniformity of the operation of each on any given animal body which it affects. OEach of the diseases propagates itself in its own form in as exact identity, as if it were a species in zoology or botany ; and in each such repetition of the disease there is a multiplication — always aJarge; and sometimes an inconceivably immense multiplication, of material which has the same infective property. Evi- dences innumerable to that effect are under daily clinical observation in this climate in instances of smallpox, measles, scarlatina, whooping-cough, enteric fever, mumps, typhus, syphilis, cowpox, diphtheria, erysipelas, hospital gangrene, puru- lent ophthalmiaiand gonorrhcea, venereal soft- chancre and rphagedsena, &c. : for, barring falla- cies, no man ever sees any one of those diseases produced by the contagium of any other of them; and any man who has before him a case of any of them can see that, however minute may have been the quantity of ; contagium by which the disease was started, the patient's diseased body (part or whole) yields for the time an indefinitely large supply of the specific, agent. It is more or less habitual to some of the diseases that the infectedness of >the patient is first made known to the observer by such general pyrexia as tells of change already far advanced in the ciiv culating mass of blood ; and it is only, aftei; this has shown itself, that other symptoms, adding themselves to the fever, complete the more or less complex type which establishes the identity of the disease. But in many of the diseases it may be the case (either naturally or as result of experi' mental infection) that the first, and in. some dis- eases the main or even the onlyy effects of the contagion are local c^an^g^, passing where we can from the first observe them ; an i the broad facta of metabolic. infection, as regards waste of bodily material with concurrent increase of contagium, are, in many such cases, among our most familia* experiences. Most instructive, too, are the fhola of contagion which are to be learnt in tho ttiidy 288 of tubercle: the contagium, introducible either by tubercular and certain septic inoculations through the skin, or internally by the infective action of the milk or diseased organs of tubercular animals if taken as food; and the contagium, when intro- duced, gradually spreading as it multiplies, and as lymph and blood carry it from the first infection- spot to other organs which now will repeat the process. And similarly in cancer (though the primary disease is at present of unknown origin and cannot be created by experiment) the repeti- tion of the primary disease in secondary and ter- tiary propagations in the body of the sufferer is one of the moststrikingof all evidences of conta- gion; because of the great number of structural types which pass under the name of cancer, and the fidelity with which each of them is repro- duced in the organ to which the contagion ex- tends. A further fact of contagion, deserving notice in the present context, is the local spread of certain of these processes by continuity of tissue; as, for instance, in the continuous ex- tension of phagedaena or hospital-gangrene from any centre of first inoculation, or of tubercular softening or cancer at the place where it begins : a mode of extension which indicates successive infective actions of matter on matter in spheres of ever-widening circumference ; ' and the like of which, but in rudimentary degree, may be traced in the areola of any acute inflammation. In the physiology of the metabolic coutagia no facts are more characteristic or more important than those which show the eelattveness of par- ticular contagia to pahticdlab eeceptivities of body. First, and in intimate connexion, as would seem, with a chemical eleoHveness of action which will presently be imputed to contagia, there is the preference which some particular contagia (however introduced into the system) show for particular organs of the body ; so that, by the exercise of this preference, there is given to each of the diseases its own set of clinical and ana- tomical characters. Compare, as instances in this point of view, the respective local afBni- ties of smallpox, enteric fever, mumps, syphilis, hydrophobia, &c. — Secondly, it may be noted that, in regard to some of the contagia, different persons, and particularly persons of different famUy-stooIcs, show original differences of sus- ceptibility; original, namely, as distinguished from others, hereafter to be mentioned, which are acquired; so that, for instance, the severity with which scarlatina or diphtheria will strike in particular families contrasts with a com- parative mildness of the same disease in other families, or perhaps even with cases of ap- parently complete personal immunity under ex- posure to the particular danger: and recent researches have seemed to suggest as possible that, in the very wide differences of degree with which tubercular disease prevails in differ- ent families, an essential condition may be, that the ft.nnilies have widely different degrees of origiuHl pradispo«ition towards some of the septic contagia.— Thirdly, there is the extremely suggestive fact with regard to many of our best- known febrilising contagia, that they run a ' Compare Tennyson's 'little pitted speck in gamerefl fruit, WUcli, rotting inwdrd, slowly moulders bU." CONTAGION. course of definite durqbtion,, and that in this course, provided, the patient do not die, ajl present, perhaps all future, suscfptUnlity to % partmilar contagiiim is ntteirh/ exhausted from the patient ; so that re-introduction of the same contagium will no more renew that patient's disease than yeast will excite a new alcoholic fermentation in, any previously well-fermented bread or wine. The inference from this fact seems unavoidable, that each such contagium opemtea with a chemical distinctiveness of elective affinity on some special ingredient or ingredients of the body,; and that exhausting this particular mate- rial in febrile process, which necessaiily ends when the exhaustion is complete, is the bodily change which the contagium 'specifically' per forms. — Of not all metabolic contagia, however. can it be said that their operation runs so definite and self-completing a coarse. For, first, there are particular acute infections which, as a rule, kill ; either (as appears to be the case in splenic fever when affecting man) because of the extreme magnitude of the transforming process which the contagium sets up, or else (as appears to be the case in hydrophobia) because the elective; in- cidence of the contagium is on an organ indis- pensable to life ; so that in such cases there is in fact hardly such an event as passing alive through the whole process of the disease. And secondly, there are the contagious dyacrasiea which are clearly characterised by their tendency to indefinite duration : syphilis, which oftener than not relapses in successive outbreaks, and often as years pass invades the body more and more deeply, and may after all never during life be ended; and tubercle and cancer, whicji, with almost invariable persistence, will in , general steadily advance month by month to infect more and more of the body till the process eventuates in death. The transmission of various contajg^ous diseases IN COMMUNITIES is of course greatly influenced, both in detail and in aggregate, by such differ- ences pf individual receptivity as were men tioned in the last section. Notably, as regards communities through which particular acute in- fections have had full run, fresh sparks, of the contagium may find little or no fuel on which to act ; and much new diffusion of the disease may not again be possible, till immigration, or births, or lapse of time operating in other ways, shall have reconstituted a susceptible population. And, given the susceptible population, circumstances of time and place are infinitely various (especi- ally as reganis quantity and quickness, of per- sonal or quasi-personal intercourse) in detennin-; ing how far this population shall have particular contagia thrown in its way. Also there are conditions, not primarily of a personal kind, which operate on a very large scale in determining the spread of some of the metabolic infections ; giving to them respec-; tively at certain, times, in ways not hitherto understood, a tipeciql increment , of , spreading- power, and in some instances also special malig- nity : and thus enabling them respectively froff time to time to come into comparative promine;ica in national life, and perhaps at once pr.sucfjess- ively in many different countries, in the form^of I so-(»lled EPIDEMICS. Thus, it is matter of familiar CONTAGION. 289 huo-wledge that the fevers -which are most habitual to this country, scarlatina, measles, smailpox, enteric fever, are of notlung like uniform prevalence, — that soarlatina.for instance, ■vfiU be three times as fatal in one year as in another, and that smallpox is liable to even oreater exacerbations; and it is known that temporary differences of this kind are not exclu- sively local, — that, for instance (to quote a late ofSeial report) ' the epidemic of smallpox -vrhioh began in England towards the close of 1870 and terminated in the second quarter of 1873 was part of a general epidemic outbreak of that disease, of world-wide diffusion, marked wher- ever it occurred by an intensity and malignity unequalled by any previous epidemic of the disease within living memory.' The wider the survey which we take of epidemiology, the more certain it becomes to us, that, outside the conditions which are independently personal or local, there are cosmical conctUwns which hare to be considered. Doubtless there are great epidemiological facts — such, for instance, as the first spreading of smallpox to America, or in our own times the increasing frequency of Asiatic cholera in Europe, which maybe ascribed to novel conditions of international intercourse : but there are others, equally great, to which apparently no such explanation can be applied. Eor what reason it is that cholera every few years has its definite fit of extension in India, — or why diphtheria, which scarcely had a place in history till it overran Europe in the 16th century, and which since then had been rarely spoken of, began again some twenty-odd years ago to be comparatively important in England, — or why the plague of the Levant has for the last two centu- ries been so unfamiliar to us, — or why the yellow fever of the Mississippi has in particular years raged furiously in parts of Europe, — or why our black-death of the 14th century, though appar- ently still surviving in India, has never but that once been in Europe, — or whither has gone our sweating-sickness of three centuries, ago, — or whence have come the modern epidemics of oerebro-spinal meningitis ; these, and many like questions, which cannot at present be answered, seem to be evidence enough that, in the making of epidemics, contagion and personal suscepti- bility may be factors in a partly amditional sense. Influences which are called 'atmospheric' — the various direct and indirect influences which attach to the normal succession and occasional abnormality of seasons, in respect of the insola- ' tion of our planet, and of the temperature and humidity of air and earth — are in general far too vaguely regarded as elements of interest in the present question, but are possible factors which no epidemiologist should omit from scientific consideration. For any definite knowledge which exists aa the relation of particular conditions of season to the prevalence of particular epidemics, the reader is referred to the article Epibbmios, and to articles on the respective diseases. In the PASSAGE of the metabolic contagia feom PHiEsoN TO PEESON various agencies may be in- strumental,— bedding or clothing or towels which have been used by the sick, dirty hands, dirty instruments or otlier utensils, the washerwoman's basket, foul water-supply, stinking house-drains; 19 contaminated milk oi other food, the common atmosphere, &c. j but differences of that sort are only differences as to the mecms by which moh communication is established with a dis- eased body as brings its products into relation with healthy persons; and the disengagement of infectious products from the bodies of the sick is pathologically, the one influential fact. As regards the products which ought to be deemed infectious, the specially-diseased sur- faces and organs of the patient, and the dis- charges and exhalations which they respectively yield, must always be regarded with diief , sus- picion; but suspicion, Eoweveif much it may insist on them, must never disregard other sources of danger. Of some of the metabolic contagia we practically know, and of raany of the others we may by analogy feel sure, that, when a given body is possessed by one of them, no product of that body can be warranted as pafe not to convey the infection. Presumption against every part and product of the diseased body is by everyone readily admitted where there are vehement general symptoms of disease : but it is important to know that not only in such febrile states, but even in states of chronic dyscrasy, and even at times when the dyscrasy may be giving no outward sign, the infected body may be variously infective. Thus, in regard to constitutional syphilis, it is certain that the mere utero-catarrh^ discharge of the syphilitic woman, or the sperm of the syphilitic man, or the vaccine lymph of the syphilitic infant, may possibly contain the syphilitic con- tagium in full vigour, even at moments when the patient, who thus shows himself infective, has not on his own person any outward activity of syphilis. Similarly, in regard to tubercular dis- ease, experiment has proved beyond question that the milk of animals suffering from tubercle will, if taken as food by other animals, infect them through the intestinal mucous membrane: and there are independent reasons for believing that the tubercular eontagium (like the syphilitic) will at times during the dyscrasy be contained in the seminal fluid, and that men, tubercular perhaps only in some degree which is not im- mediately important to themselves, may by that secretion convey fatal infection to women with whom they have conjugal relations.' Kegarding many of the metabolic contagia, conclusive evi- dence exists that, when they are in operation in pregnant women, the fcetus will in general be infected by them; and this though the diseases (e.g. smallpox, cholera, syphilis) be of the most different pathological types : but with regard to pregnant animals affected with splenic fever it is noticeable that Brauell, in his ex- tensive researches, found the blood of the fcetus not to be infective. In general, each eontagium has its own favourite way ob ways op osntebino the body • and these preferences are not only of speculative interest, as attaching to varieties of nature and natural habits among the contagia, but are of obvious practical importance as measures of , the widely different degrees in which the different contagia are qualified to spre,ad in communities. Thus, inoculation at broken mrfaces of skin ' See Br. Weber, in Clin. Sac. Train., 1874. 290 CONTAGION. or mucouB membrane has long been known as the ordinary mode by Tphioh the infections of syphilis, hydrophobia, splenic fever, cowpoi, and farcy or glanders, get admission to the body; and our best knowledge of some other infec- tious diseases (notably of tubercle) has been derived from inoculations intentionally made •with their contagia for purposes of study. While probably ajr infections which tend to be of general action on the body can be brought into action in that way, and while some infections are not known to pass by any other mode of transmission, there are many infections which spread freely from subject to subject by atmo- spherie and dietetic commtmioation; and the meaning of these preferences is hitherto not fully known. It seems that some contagia are so acted upon by air and water, that they seldom or never reach the body in an effective state by those common means of communication, — some hardly, if at all, by water, and some not by air except with very close intercourse ; and further, that, of con- tagia which reach the body in an effective state, some require, while others do not require, that an abnormal breach of surface shall give them special opportunity for taking hold. In some of the cases where a disease can be propagated in both ways, — i.e., certainly in smallpox, and apparently also in bovine pleuro-pneumonia, the artificially-inoculated disease tends to be much milder than the disease otherwise contracted ; but pathologically it is difficult to conceive any essen- tial difference between those different modes of contagion. It may be presumed that, in the modes which are not by true inoculation, acts which are comparable to inoculation take place on internal surfaces ; that, for instance, when particles of scarlatina-contagium are caught in the tonsils, or inhaled into the bronchi, or swallowed into the stomach, they begin by pene- trating the texture of the mucous membrane, and by thus effecting as real an inoculation, with regard to the blood, as that which art or acci- dent provides in other cases through the punc- tured skin. That previous abnormal breach of sur&ce by artificial puncture or otherwise is not necessary to allow the infection of mucous sur- faces is illustrated in ophthalmia and gonor- rhcea ; where apparently no other condition has to be fulfilled than that a particle of the blen- orrhagie contagium shall be deposited on the natural surface of the mucous membrane. It deserves notice that, while a considerable number of the worst diseases of the domestic animals admit of being communicated to man by artificial inoculation atmospheric communication seems to be very inapt, if not absolutely unable, to infect man with any one of them ; and in this connection it may be of interest to remember that syphilis, one of the most familiar of human infections, but hitherto not traced to any brute ancestry, differs from our other current infectious in re- quiring inoculation to transmit it. When any^ metabolic contagium enters the animal body, it requires an interval of time, and m most cases a considerable interval, before its morbific effects can become manifest even to skilled observation. The period of latency or so-called incubation varies greatly in different eases. In hydrophobia it is very rarely less I than of one month, is certainly often of several months, and is said to be sometimes of years. In syphilis the inoculated spot remains generally for at least a fortnight, and may remain even as much as five wee&, ■without any ostensibit change ; and the roseola of the general infeotioa will not be seen till some weeks later, when generally at least three months will have elapsed since the first inoculation. In the acntt eruptive fevers, when their contagium is trans- mitted by air, the first changes which ensue on infection are not external, and we cannot be snra what early internal changes may take place ; int in smallpox, the fever (which is the first overt sign) does not attract notice till about the twelfth day after infection, nor the eruption tiU two days later; and in measles the incubation-time, though perhaps less uniform, seems to be little (if any) shorter than that of smallpox. The septic con- tagia and the contagium of splenic fever seem to be of particularly quick operation ; but even the most virulent septic contagium, when without admixtures which tend to complicate its action, will not begin sensibly to derange the infected animal till at least several hours after it has been inoculated. As regards the contagia last referred to, it is conceivable that the sefemulti- plication of the contagium in the form in which it proves fatal to life is a process which goes on continuously and nniformly from the moment ai inoculation to the moment of death, and thatthe moment when signs of general derangement be- come manifest is the moment when this uniformly advancing process has accumulated in the system a certain quantity of result: — but it does not seem easy to apply this explanation to, the dis- eases of long incubatory period; and, we can hardly conjecture what may be the latent pro- cesses — for instance of smallpox, during the first ten or more days after contagium has been received. It is not yet possible to say, in any universal senpe, with regard to the metabolic contagia, what is the ESSENTIAL CONSTITUTION of ' contagious matter,' or what the intimate natoeb of the 'transforming power ' which the particle of such matter exer- cises on the particles which it infects.— As regards the question of the roECE, chemists, when they refer in general terms to the various acts which they designate acts of fermmlit- tion, allege that certain processes of change in certain sorts of organic matter induce charac- teristic changes in certain other sorts of organic matter, not by the common chemical way of double decomposition with reciprocally new com- binations, but (so to speak) as a mere by-play or collateral vibration-effect of the chemical force which is in movement; and though language can hardly be more vague than thisfoi any scientific purpose, it expresses clearly enough the conviction of experts that a certain great force in nature lies beyond their power even of definite nomenclature, much more of exact iden- tification and measurement. In that most interesting, but most difficult and hitherto almost uninvestigated, branch of chemical dynamics, we are supposed to have our nearest clae_ to the scientific problems of the present subject-matter. It may be conceded ttat the ' contact-influences ' which are dimlv recoenised CONTAGION. 291 as causing the fermentatoiy changes of dead organic matter have apparent analogues in many of the morbific influences of contagion : for the changes which chemists call ' fermenta- tory'are all catalytic or disintegrative of the organic compounds "which they affect; and when living protoplasm is brought by contagion into processes of characteristio decay, the analogy seems sufBciently close to justify the word aymotie in the naming of the nature of the pro- cess. But it must not be forgotten that, among immediate effects of contagion in the living body, are cases vherein the process (so far as ire can 3*t see) is primarily not eatalytio or dis- :ntegiative, but, on the contrary, anaplasiio or con-structive. Thus, when tubercle gives rise 00 tubercle, whether by secondary and tertiary infection in a single diseased body, or by infec- tion from the sick to the healthy, each new tubercle wMch the contagion brings into being is a growth-product of the texture which bears it. And similarly, when the innumerable varieties of cancerous tumour propagate themselves by contagion, each after its special type, in the bodies of the respective sufferers, it is growth, not disintegration, which we first see. It would seem that in those cases of anaplastic 'contact- influence ' something far beyond the analogy of chemical fermentations must be involved; and, in view of some of theto, the physiologist has to bethink himself of the analogy of that 'contact- influence' which becomes the mainspring of all normal growth and development, when the ovum receives spermatic impregnation. — As regards the ultimate okganio ooNSTiTriioN of the several metabolic contagia — (each of them of course abstracted from accidental admixtures, and seen or conceived in the smallest and simplest units of quantity and quality in which its specific force can be embodied) — modem re- ■ search seems more and more tending to show that the true unit of each metabolic cpnta- gium must either be, or must essentially include, a specific living organism, able to multiply its kind. For with regard to those other contagia (as we may properly call them) which spread formentatory processes in common external nature, and of which it is as clear as of the morbific contagia that they multiply themselves in proportion as they act, it seems to be estab- lished beyond reasonable doubt that the ' self- multiplication ' of each of them as it acts is the infinite multiplication of a specific microphyte ; and that this microphyte (acting apparently by means of a matter which it produces and from which it can be mechanically separated) is the essential originator of the fermentation.' This being the case in regard of those fermentations, it seems probable that the same is in substance true of the, specific morbid changes which extrinsic contagia produce in the materials of * The doefcrine to which the wor^s in parenthesis refer (that the microphyte is not iteelf the ferment, but the prodncer and evolver of the ferment) tends to bring the case of these ferments into parallelism with that of the chylopl5etlu and other functional ferments which more highly organised creatures produce for the purposes Cjf their owTi economy. In the latter case the distinc- tion between the ferment-yielding live bodies (say cer- tain gastric cells) and their not-live product (say pepsin) II already familiar. the living body: probable, namely, that lo'w, self-multiplying organic forms, specific in each case for the particular disease which is in que»- tion, are essential to each morbid poison ; that the increase of each contagium as it acts is the characteristic self-multiplication of a liimg thing; and that this (however obscure may yet remain its mode of operation) is the essential originaior of change in the affected materials of the diseased body. The fact that low organic forms of the sorts now spoken of have often, or generally, been seen in the morbid products and tissues of per- sons with zymotic disease, would not by itself be a proof, or nearly a proof, that the forms are causative of the morbid change : for obviously they might be mere attendants on the necrosis and decomposition of bodily material, availing themselves of the process (just as certain insects would) to feed and multiply : and in many of the eases in which micrococci have been seen in morbid material, no direct proof could be given that the meaning of their presence was more than that. There are, however, some cases in which this proof has been completely established; and though such cases are at present but few, the significance of each of them in aid of the inter- pretation of other cases is of the highest im- portance. The researches of successive able observers in, regard of the splenic fever of farm-stock, and those of Dr. Klein in regard of the ' pneumo-enteritis ' (as he names it) of swine, have shown that in each of these cases the microphyte which attends the disease is botanieally specific; that it and its progeny can be conducted through a series of artificial cultivations apart from the animal body; and that germs thus remotely descended from a first contagium will, if living animals be inocu- lated with them, breed in these animals the specific disease. It is equally well known that the organisms (spirilla) which are found multi- plying in the blood during the accesses of relaps- ing fever are botanieally specific ; but in regard to this disease, experimental proof has not hitherto been given that the spirilla, if sepa- rately inoculated, will infect with relapsing fever. Studies as complete as those which have been made in splenic fever and pneumo- enteritis will no doubt sooner or later be made in regard to many other of the diseases, but their progress will necessarily be slow ; partly because the objects which have to be scrutinised, and to which specific characters have to be assigned, are so extremely minute, and often so similar among themselves,, that none but very skilled and very patient microscopical observers are competent to pronounce on them; and partly again because the conditions of the case are siich as to limit very closely the field within which the essential experimental observations cap. be made. Meanwhile, however, the two disease^, regarding which the larger knowledge has been obtained, must be regarded as higUy suggestive in regard of other diseases of the same patholo- gical group, and particularly as givipg impor- tance to fragments of evidence (not by them- selves conclusive) which have beea gathered of late years in studies of some of these other diseases. Eminently this is true of the large family of the septic infectious— including on the 292 one hand erysipelas and pyaemia with its conge- ners, and having on the other hand tuberculosis intimately associated -with it ; and almost equally it is true of enteric fever and cholera and diph- theria, and of the smallpox of man and beast. Thus, though it -would be at least premature to say of these diseases that they certainly have as their contagia microphytes resfpectively tpecifio to them, it seems at present not too much to say that probably such will be found the case ; and if as much may not yet be said of many other diseases which are due to metabolic contagia, it must be remembered that the right lines of study relating to contagia in this point of view have not till within very recent times been opened. Of the NATtjEAL HisTOET of the contagia, con- sidered independently of the part which they play in the living body, there are hitherto only the beginnings of knowledge. The absolutely first origin of contagia may perhaps not be more within reach of scientific research than the abso- lutely first origin of dog or cat ; but their nearer antecedents — the states out of which they come when first about to act on the living body, and generally the variations which they and the common ferments exhibit under natural and artificial changes of circumstance, are within easy reach of investigation ; and those humbler studies are lilcely to give very useful results. For some of our cases we seem to have an instructive analogy in the facts which Professor Hosier has put together in explanation of the blue-milk contagium of dairies : facts showing that the omnipresent penioillium glaucum, if its spores happen to alight in particular (morbid) sorts of milk, will operate distinctively on their casein as an aniUn-making ferment, rendering the milk blue and poisonous, and imparting to each drop of it the power to infect with a like zymosis any normal milk to which it may be added.' In our own more special field, patholo- gists have already learnt that certain of the so-called 'morbid poisons' — the contagia of pyaemia and tuberculosis, are inti- mately related to the common ferment or fer- ments of putrefaction ; and that the most vehe- ment of these contagia can be developed by the artificial culture of successive transmissions in the living body from the comparatively mild contaginm of any common iTijlammatory process." Two other directions suggest themselves as likely to lead to fields of useful observation and experiment. On the one hand, in compara' tive pathology, and with the tracing of contagion from animal to animal, there is the possibility that at last some lower and relatively worth- less order of animals may be found the starting-ground of fatal infections for higher orders ; and this, perhaps, by contagia which in their former relations are of mere infiammatory significance. On the other hand, in geographical pathology, and with the tracing of contagion from place to place, local centres of contagiom- ' Tirch. Arch., vol. 43. * See particnlarly Professor Sanderson's papers in suc- ceSBiTe yearly Tolniaes of Reporli of the Medical Officer relation between morbid mental manifestations and morbid conditions of the brain, and their joint relation to the bodily symptoms, remain involved in great obscurity. The objective symptoms of cortical lesions depend on their locality, and on whether they exercise an irritative or destractiye influence on the parts they invade. From the localisation point of view alone the intimate nature of the mor- bid process is unimportant, except in so far as its irritative or destructive character is concerned. Lesions, such as tumours, which from their very nature exercise important indirect effeots on the encephalon as a whole, apart from their effects on the regions which they directly invade, can rarely be exactly localised, owing to tho difBculty of separating the direct and indirect symptoms from each other and referring each to its exact cause. Also no rigid conclusions as regards localisation can be drawn from morbid affections of the hemispheres which extend ove* a large area, such as the various forms of menin- gitis and meningo-encephalitis. In all these oases the nature of the affection must be diag- nosed from its own general and special cha- racters ; its position and extent in the brain being arrived at approximately from a considera- tion of the effects of accurately circumscribed lesions, as determined by careftil clinical and pathological observation and physiological ex- periment. The brain may be considered as divided into a inoior and a seTisori/ zone. Motor Zone. — The motor zone includes the convolutions bounding the fissure of Rolando, viz. the ascending frontal and the bases of the three frontal convolutions, the ascending pari- etal and postero-parietal lobule, and the in- ternal surface of the same convolutions or para- central lobule. In this zone are diflferentiated centres for the movements of the limbs, head, and eyes, the muscles of expressipn, and those of the mouth and tongue. The centres of tho log and foot are situated in the postero- CONVOLUTIONS OF THE BRAIN AND CORTEX CEREBRI, LESIONS OF. 297 parietal lobule, those for the arm in the upper third of the ascending frontal, those for the hand and wrist in the ascending parietal, those of the facial muscles in the middle third of the ascending frontal and base of the second frontal, those for the mouth and tongue at the lower third of the ascending frontal at the base of the third frontal, and for the platysma at the lower extremity of the ascending parietal, just posterior to the mouth-centre. The posterior third of the upper frontal convolution and corresponding part of the second frontal, contain the centre for the lateral movement of the head and eyes. The frontal regions in advance of this centre, though anatomically related to the motor divi- sion of the internal capsule, do not seem directly connected with motor manifestations as judged by the negative effects cither of irritation or ex- tirpation. Irritative lesiom of the motor zone proper, such as may be induced by syphilitic lesions, tumours, spicula of bone, depressed fractures, thickemng of the membranes, &c., cause con- vulsions, which may remain limited to one limb or one group of muscles without loss of conscious- ness, or affect the whole of the opposite side with loss of consciousness, or become more or less bilateral with all the symptoms usually ob- served in so-called idiopathic epilepsy. If the convulsive phenomena begin always in the same way, and if they frequently remain localised in one limb or one group of muscles, and especially if paralytic symptoms manifest thehiselves, the exact position of the lesion in the opposite hemisphere maybe accurately diag- nosed. {See cases by Hughliugs Jackson, Clini- tal and Physiological Eeeearches on the Nervous System (reprints), 1873 ; Dr. Dresohfeld, Latimt, Feb. 24, 1877 ; Dr. BramweU, h^. Mid. Jown., Aug. 28, 1875 ; MM. Charcot and Pitres, Eevue Mensuelle, 1877.) Destructive lesions of the motor zone cause general or limited paralysis of voluntary motion in the opposite side of the body, according as the lesion affects the whole of the motor zone or is limited to special centres ' within this area. The causes of destructive lesions of the cortex may be various — hsemorrhage, laceration by wounds, &c. One of the most common causes is embolism or thrombosis of the arteries sup- plying the cortical motor area. These are de- rived from the Sylvian artery of the middle cerebral. The cortical branches may be ocolud-- ed without interfering with the circulation in the corpus striatmn, which is supplied by special branches, as shown by the researches of Duret and Heubner. When the motor zone is affected by general destructive lesion, complete hemiplegia of the opposite side results, in all respects like that resulting from destructive lesion of the corpus striatum and anterior portion of the internal capsule. _ In this form of paralysis the loss of motion is most marked in those movements which arc most independent, hence the arm is more paralysed than the leg or face, and the hand more paralysed than the shoulder move- ments of the arm. This has been accounted for by the fact, that the centres for bilateral move- ments are intimately associated in the lower ganglia ; hence the stimulus from one hemisphere can to a certain extent call forth the action of Vta. 12.— Side view of the Left Hemisphere of the Monkey. The areas have the some signification as in the next figure. I Fis. 18.— Side view of the Left Hemisphere in Man, with the areas of the cerebral convolutions. The effects of stfmulatton of each area, as ascertained .by experi- ments on the brain of the monkey, are subjoined. 1. Poatero-parietal lobule. Advance of the opposite hind limb, as m walking. 2, 3, and 4. Around the upper extremity of the fissure of Rolando. Oomplox movements of the opposite leg and. arm, and of the trunk, as in swimming. a, &, c, d. Ascending pai-ietal convolution. Individ- ual and combined movements of the fingers and wrist of the opposite hand. Prehensile movements. 5. Posterior extremity of the superior frontal convolu- tion. Extension forward of the opposite arm and hand. 6. Upper part of ascending frontal convolution. Su- pination and flexion of the opposite forearm. 7. Median portion of ascending frontal convolution. Betraction and elevation of the opposite angle of the mouth. ' 8. Lower part of the ascending frontal convolution. Elevation of ala nasi and upper lip, with depression of lower lip. 9 and 10. Inferior extremity of ascending frontal con- volution (Broca'B convolution). Opening of the mouth with (9) protrusion and (10) retraction of the tongue. Begion of aphasia.. Action bilateral. 11. Between the inferior extremities of the ascending fi-ontal and the ascending parietal convolutions. Ke- tractioi^ of the opposite angle of the mouth; and the head turned slightly to one side. 12. Posterior portions of superior and middle frontal convolutions. Eyes opened widely;, pupHa dilated; head and eyes turned towards opposite side. 1 3 and 18'. Supra-marginal lobule, and angular gyrus. Eyes moved towards the opposite side, with an upward (18) or a downward (13') deviation. The pupils gener- ally contracted. (Centre of vision.) 14. Infra-marginal (superior temporossphonoidal) con- volution. Pricking of opposite ear; head and eyes turned to opposite side; pupils largely dilated. (Centre of hearing.) 298 CONVOLUTIONS OF THE BRAIN AND CORTEX CEREBRI, LESIONS OF. the conjoint motor nuclei. The electrical con- tractility and nutrition of the muscles is not affected by paralysis of cerebral origin. The nutrition of the muscles may, however, suffer from disuse, and frequently paralyses of cortical origin are followed after a time by Mgidity and contraction, accompanied with descending secon- dary sclerosis of the motor tracts of the crura, pons, and lateral tracts of the spinal cord. In some cases the descending degeneration invades the anterior cornua of the spinal cord, and atrophy of the paralysed muscles ensues. Occa- sionally from limited lesions of the cortical motor area complete hemiplegia may occur on the opposite side for the time at least. This is to be explained by the fact that sudden estab- lishment of a destructive lesion may cause such commotion or perturbation of the centres in general, that their functions are for the time suspended. But in such cases those centres which have been only functionally suspended will a^gain resume their functions, and the paralysis will disappear except of those movements the centres of which have become permanently dam- aged. Limited lesions of the motor zone cause paralysis of those movements the centres of which the lesion invades. The result is not complete hemiplegia, but a monoplegia or disso- ciated paralysis. Hence, from a cortical lesion we may get a paralysis of the arm, or of the arm and face, or of the leg and arm, or of the face alone, or of the lateral movements of the head and eyes. Numerous examples of these mono- plegise resulting from limited cortical lesions have been collected by Charcot and Pitres (Sevue Menmelle, Jan. 1877. et seq. ; abstract in Lond. Med. Becord, April, 1877). The morbid process which, while circumscrilaed at first, causes a monoplegia:, may advance to other centres, and after a time produce general hemiplegia of the opposite side. Hemiplegia so resulting is a succession of monoplegise, and is a sure indi- cation of cortical disease. It is to be noted that destructive lesion of the mouth-centre (Broca's region) on one aide does not causa para- lysis of articulation, owing to the fact that each centre has a more or less complete bilateral influence over the movements of the mouth and tongue. Destructive lesion of this centre in the left hemisphere generally gives rise to aphasia without paralysis of articulation (see Aphasia). In bilateral lesions there is both aphasia and paralysis of articulation {see Dr. Barlsw's case, Brit. Med. Jovr. 1877, vol. ii. p. 103). Limited cortical motor lesions are frequently associated with transitory rigidity of the opposite side of the body ; and if the lesion is complete, the local paralysis or monoplegia will remain per- manently, and may bo accompanied by late rigidity and descending sclerosis of the motor tracts, as has been shown by Charcot {pp. cit.). These monoplegise frequently alternate with unilateral convulsions, owing to the morbid pro- cess occasionally inducing irritation of the neigh- bouring centres. Destructive lesions of the frontal and orbital regions cause no motor paralysis or any very evident physiological symptoms. In the recorded cases of bilateral lesions symptoms of dementia to a greater or less extent have been noted. Sensory Zoue. — ^From experiments on tha brain of monkeys by means of the complemental methods of excitation by the electric current, and destruction of the grey matter of the cortex, the writer has arrived at the conclusion that in the regions lying posterior to the motor zone there are differentiated centres of sight, hearing, touch, smell, and taste. The sight-centre is situated in the angular gyrus, and embraces also th^ occi- pital lobe — the oecipito-angular region; the centre of hearing is localised in the superior temporo-sphenoidal convolution ; the tactile cen- tre is situated in the hippocampal region ; while the centres of smell and taste are situated to- gether at the lower parts of the temporo-spher noidal lobe. Destructive Lesions. — Unilateral destruction of these sensory centres does not, however, appear to permanently abolish sensation on the opposite side of the body. It is only when the lesion is bilateral and in corresponding points that the loss of sensation is thorough and per: manent. Hence the fact is to be accounted for, that in man, as a rule, unilateral destructive lesions of the regions indicated are latent, or not, so far as at present known, accompanied by any objective symptoms. Numerous cases of this kind are on record. No secondary descending, degeneration of the spinal cord has been ob served in these cases. Until evidence is increased from human por thology of the occurrence of loss of sensation from lesion of the cortex — and this the writer holds is to be looked for in bilateral destructive lesions — pathologists in general reserve their opinion as to the explanation of the latency o£ the lesions in question. But though the pathological evidence in favour of the localisation of distinct sensory centres is as yet comparatively slender, it is daily increas- ing. Though numerous cases are on record of lesions in the angular gyri and occipital lobca without symptoms as regards vision, there aro others, more particularly of lesions of the medullary fibres of this region, in which hemiopis, towards the side opposite the lesion has been observed. Some of Uiese cases may perhaps be explained by direct or indirect lesion of the optic tract, but others cannot be so accounted for. For other facts bearing on this question the reader is referred to a paper by the writer on Cerebral Amblyopia and Hemiopia, Brain, xii. 1881. , It has been established by the researches of Turck, Charcot, &e., that destructive lesions of the posterior third of the internal capsule, ex- ternal to the optic thalamus, cause hemianaea- thesia of the opposite side of the body. The hemiansisthesia of organic origin exhibits the same symptoms as are observed in what is termed hysterical hemianaesthesia. In this condition there is loss of tactile sensation and more or less complete loss of sight, hearing, smell, and tasli, on the side opposite the lesion. The affection of sight, which is not accompanied by any changes in the eye discoverable by the ophthal- moscope, is characterised by dyschromatopsy, and a remarkable contraction of the field of vision. The loss of hearing is very marked, if not absolute, and similarly as regards smell CONVOLUTIONS OF THE BEAIN. and taste. It is evident that the lesion situated in the medullary fibres is not an affection of sensory centres, and that it is simply a solution of continuity of the centripetal paths -which ra- diate out into the differentiated sensory centres of the cortex. The exact destination of the special sensory paths the writer has indicated above, and to this the special attention of physi- cians and pathologists should be directed. The ■writer is likewise of opinion that the loss of smell and taste, which is occasionally observed to result from a blow on the occiput or vertex is in many cases due to injury by counterstroke to the centres of smell and taste, which are situated in such a position as to be specially affected by violence so directed. There is no doubt that in some cases the loss of taste might be accounted for by rupture of the olfactory tracts or nerves, such as those in which taste is lost only for flavours, which are compounds of smell and taste. But there are others in which there has been clear loss both of smell and taste independently of each other; cases which can only be satisfactorily accounted for, in the writer's opinion, in the manner which he has indicated. Irritative Lesions. — Though the pathological evidence in -reference to the localisation of sen- sory centres is as yet but deficient, at least as regards paralysis of the special senses from destructive lesions of the cortex, there is good reason for believing that in cases of insanity, accompanied by sensory hallucinations, as also in certain cases of epilepsy ushered in by sub- jective sensations, such as flashes of light and colour, loud sounds, disagreeable tastes and smells, &c., the phenomena are the result of some morbid irritation of the cortical sensory centres, the anatomical substrata of ideation. B. f EBIilEB. CON V UliSIONS. — ^Definition. — ^This term is commonly given to more or less general, pur- poseless muscular contractions, occurring simul- taneously and successively for a variable time. It is also, however, applied at times to certain more localized purposeless contractions, though these would be more appropriately (and are in the ma- jority of cases) termed Spasms. The latter, like Convulsions, are of two kinds, tonic and clonio. Classifications. — Convulsions have been va- riously classified by different authors according to the different points of view from which they have been regarded. Looking to their causation, there is both a clinical and a physiological divi- sion into classes. From the former standpoint we have (1) primary or essential convulsions; (2) sympathetic convulsions; and (3) symptomatic convulsions; whilst from the physiological point of view they have been divided into (1) centric and (2) excentric. These classifications are arbi- trary and -will not stand the test of a critical ex- amination, though the first ofthemistoa certain extent useful. Again, looking to the distribution of the convulsions, or to the parts involved, their classification by different writers may be sum- marized as follows: — (1) External — a, general; 6, unUateral; e, partial; (2) Internal. These various terms need little explanation, though something requires to be said in regard to them. CONVULSIONS. 299 Convulsions are termed primary or essential when they occur either -without assignable cause, from mental or moral perturbations, or as a re- sult of some local irritation. They are called sym- pathetio when the convulsions declare themsel-res as a prelude to, or in the com-se of, any of th« specific fevers, as a consequence of acute pul- monary or renal affections, or in association -with disordered states or structural diseases of any of the organs of the body other than those of the nervous system ; whilst the name sympiomatio has been applied to the convulsions which occur as a result of injury or structural disease of the nervous system itself. The unilateral convulsions which affect one half of the body only, as well as other more partial convulsions, are almost en- tirely confined to this latter group, though gene- ral convulsions of the symptomatic type are perhaps just as frequently met with. The so- called mtemal convulsions constitute an ill-de- fined group, the members of which are scarcely worthy of the name of convulsions at all. They are rather tonic or clonic spasms of particular parts. The best known member of this group is laryngismus stridulus {see separate article thereon), though we may also include another much less grave, though often obstinate malady, viz. a spasmodic and frequently recurring hic- cup. Some would include angina pectoris also in this group. Con-vulsions, either tonic or clonic, or both, enter into or form the semeiological basis of five principal diseases having separate places in our nosology. These are Eclampsia, Epilepsy, Teta- nus, Hydrophobia, and Chorea. All but the first of these diseases -will be fully considered in their respective places, so that Eclampsia alone would remain. But Eclampsia and Convulsions are con- vertible terms, meaning almost absolutely the same thing. The former term, indeed, is useless except for the mere purpose of literary precision. In epilepsy and in eclampsia we have equally to do with convulsions, which are now admitted by almost aU modem -writers to be quite indistin- guishable from one another. The former name, however, is given to convulsions which have a known tendency to recur at variable intervals ; whilst the latter has been commonly applied to convulsions which are either solitary or, if not exactly so, which occur as a closely successive cluster or group, more or less distinctly sym- pathetic with some general or local bodily con- dition. Seeing that there is, in a very large number of cases, almost nothing in the nature of the attack itself to enable a medical man, called to a patient in convulsions for the first time, to say whether he has to do with an attack which will be repeated or not, it is easy to understand that eclampsia is a word more frequently to be seen in books than to be heard at the bedside. In books we may read of eclampsia neonatorum, the eclampsia of parturient women, and ursemic eclampsia; though the more common clinical equivalents are infantile convulsions, puerperal convulsions, and uremic con-vulsions. The dis- tinction between epilepsy and eclampsia is, there- fore, one which is to a veiy great extent purely artificiaL Convulsions have a frequent though less con- stant relationship also with many other affeo- 300 CONVULSIONS. tions, such as general paralysis of the insane, ttibereular meningitis, chronie hydrocephalus, hemiplegia, and hysteria. Etiology. — The causes of convulsions are oftentimes more than usually complex, consti- tuting a web of causal conditions partly made up of (a) predisposing, partly (i) of exciting, and partly (c) of proximate elements. It is often the fashion to pick out some one of the most promi- nent or easily recognizable of these factors, and speak of it as ' the cause' of the attack. It must never be forgotten, however, that this so-called cause, in any given case, may be able to act as such only when in conjunction with certain other more obscure, though perhaps not less potent, co-operating conditions. Without the conjoint influence of the latter it might have been quite powerless to produce any such results. Hence the proverbial uncertainty in regard to the action of any of the more important factors, or so-called ' causes,' upon different individuals whose age, state of health, predisposition, or surrounding conditions are not similar. The question of the causation of convulsions resolves itself, however, into two distinct depart- ments, one of which is strictly clinical in cha- racter, whilst the other is more strictly physio- logical. It is one thing for the medical man to ascertain what are the particular individual states, conditions of life, and occurrences, physical or moral, which have contributed to induce an at- tack of convulsions (to ascertain which he studies the ' predisposing ' and • exciting ' causes of the disease) ; but it is quite a different problem when he endeavours to unravel, by anatomico-physio- logioal data, the actual mode of production of the convulsions. In this latter part of the inquiry he has to do with what are called ' proximate ' causes, and is brought face to face with a problem still involved in great obscurity, and concerning which the most opposite views are held by lead- ing pathologists and physiologists. This second part of the problem of causation, for the present, concfiTTis us less than the more strictly clinical side of the inquiry, and it will be only inciden- tally referred to in the present article. It will be faUy considered in the article Epilepsy. Predisposing Causes. — The most important of these is the existence of an unduly excitable nervous system — one in which there is an exalta- tion of the tendency to produce reflex movements ^an 'undue mobility of the nervous system,' as it is sometimes called. This is a state of things which is naturally more marked in women than in men, and is also notably prominent in young children of both sexes. It is, moreover, much exaggerated in some children of nervous habit, who, besides being unduly emotional or exci- table, are very prone to start or tremble on the least noise, and are subject to muscular twitch- ings in various parts of the body. With in- creasing age, and more especially in the male sex, we find the sensorial and emotional nerve- centres becoming less excitable, owing, in great part at least, to their more complete subordina- tion to the controlling or inhibitive influence of the developing cerebral hemispheres. The predisposing groundwork being of this naturp, how is it caused, or to be accounted for? (1) It maybe inherited from one or both parents, or from grandparents, who may themselves have possessed a nervous system of this type; and may, morever, have been subject to fits or other weH-marked disease of the nervous system. But though not J inherited in the strict sense of the term it may (2) be connate; the patient may always («'.«. from birth) have possessed a nervous system of this type, as an accompaniment of the mere low vitality which is often seen in children born from parents who are simply weak and debilitated, or in those whose parents have been advanced in life. (3) At other times the nervous system may have acquired such predis- posing characters some time during the life of the individual (especially during childhood or adolescence) owing to the action of various sets of conditions, some of the best established of which are these : — (o) The cachexia sometimes following measles, pertussis, &c. ; (J) insufficient or improper food; (o) chronie diarrheea; {d) haemorrhages or exhausting discharges. If we turn now to the various exciting causes we find these so powerfully influenced by the age of the patient, as to make it desirable to consider them in reference to different periods of life, which we may artificially though conveniently mark off from one another. "" Infancy (from birth to end of 2nd year). — In certain cases convulsive attacks are congenital ; and here perhaps the most frequent exciting causa is a meningeal effusion of blood which presses upon and irritates the surface of the brain — the extravasation having in some cases been occa- sioned during parturition where it has been prolonged or unnatural. These congenital attacks , are most frequently associated either with more or less marked hemiplegia, or with a subsequent partial or distinct condition of ameutia' or idiotcy. Such unfortunate infants may contirifie quite unable to stand or even sit up ; they remain unable to speak, and, as in a case which I have re- cently seen, the child may be quite blind. Menin- geal or superficial haemorrhages may also occur in young infants, under the strain of the mechani- cal congestion produced by violent fits of cough- ing in pertussis or bronchitis, and in some of these cases such effusion may be followed by convulsions. Pits in infancy may also follow falls or blows upon the head, though at this early age such occurrences are comparatively rare. In infancy, agalin, convulsions m-iy usher in or subsequently supervene in almost any acute, disease, this being especially the case with measles, scarlet fever, and other of the exanthe- mata ; in pneumonia or bronchitis ; and alsoin tubercular meningitis. But, still more frequently, convulsions in. in- fancy are excited by mere peripheral irritatipps^ as during the piocess of teething, from an over- loaded stomach, or from indigestible fpod. Diar- rhoea, worms, &c., also take their place as more or less frequent excitants of convulsive parox- ysms in infants — though worms only begin to appear towards the end of this period. But though irritations in the field of distribution of the 6th and pneumogastric nerves are especially potent in exciting convulsions, irritations of other parts of the body may also lead to similar results, whether they are occasioned by tlie injudicipu|. disposition of pins, by tight strings wouriding'or CONVULSIONS. 301 irritating the skin of the body, or by any other meanB. The more distinctly predisposing con- ditions ejdst, the more frequently wiU. any or all of these exciting causes give rise to an attack of conTulsions. Lastly, an infant which has taken the breast of a woman who has shortly before been much perturbed by Tiolent anger, grief, or any other strong emotion, may thereafter, if predisposed, be seized with convulsions — ^probably owing to the milk of the nurse haying been so altered in quality as to have led to gastric trouble and iiiitation in the infant. CMdhood (from the 2nd to the 13th year). — Most of those exciting causes which are influential during the last period continue to be occasionally operative in this — especially during the first half of it. Meningeal. heemorrhages are now rarer, though they may still occur during violent par- oxysms of coughing, and also from falls or blows upon the head. The latter causes of hsemorrhage may, however, act in producing fits in other ways, e.g. by concussion, shock, &c., and they now come t;o be more frequently operative. The exanthe- mata are still apt to be preceded or associated with convulsive attacks; andirritations,especiallyfrom teething or irritants (undigested food or worms) in the intestinal canal, are also still apt to be fol- lowed by such a sequence. Durihg this period another cause of consider- able potency comes into operation with great frequency, and this is fright. The first fit either follows the fright more or less immediately, or it may not take place for days — perhaps for weeks — after the sudden emotional disturbance. During the interval, however, the health and mental con- dition of the child is generally obviously dis- turbed. Proper treatment at this stage may pre- vent the occurrence of fits. Scrofulous tumours in the brain sometimes help to determine con- vulsions in children. ,, Adolescence (from the 13th to the 20th year). — ^Fright or other sudden emotions, falls upon or blows about the head, still appear as frequent exciters of convulsive attacks which recur (epi- lepsy) at this period of life, though meningeal l^sBmorrhages, acute diseases, and peripheral irri- tations are much less frequently operative than at earlier periods, since the special irritability of the nervous system characteristic of childhood decidedly abates as the cerebral hemispheres develop and begin to exercise a more powerfully controlling influence over the lower centres. Other and new causes, however, come into play at this epoch. The establishment of puberty is a kind of crisis during which, independently of all other causes, convulsions or fits may be initi- ated in those whose nervous systems are at all predisposed towards such an occurrence. This is more especially so in the case of the female, partly because of the existence of a more frequent predisposition in persons of this sex, and partly because of extra excitations in association with the establishment of the catamenia^whether this be brought about imperfectly or in a natural manner. Ovarian or uterine irritation, or irre- gularity of the functions of these organs at any part of this period, may help to occasion fits which may or may not take an hysterical type. Masturbation may alK b« added as an occa- sional provocative of epilepsy at this critical period of life, though I am inclined to think too much stress is often laid upon this as a oauso. When operative this mode of causation occurs more frequently with the male than with the female sex. Excessive study and mental application, as well as worry or anxiety, must also undoubtedly be enumerated amongst the causes of epilepsy at this period of life. Neither must we forget the possible existence of aneurysms of the arteries or of morbid growths in connection with some portion of the brain or its meninges, either of which may actas occasional excitants of epileptic paroxysms. This cause also figures in earlier periods of life — ^more es- pecially in those, of a scrofulous type. And in some of such cases the new-growth may lead to the supervention of chronic hydrocephalus, and thus render the occurrence of convulsions even still more likely. , Early Adult Age (20-40 years) — Fits originate much less frequently during this period of life than in adolescence or childhood. They are, however, apt to supervene more especially when the general health, is lowered under the influence of various exciting causes. Grief and mental worry, more especially when combined with long- continued bad sleep, and the labours or cares of business, are then apt to induce them. Blows or fiills upon the head may still be followed by attacks of this kind, though perhaps with less frequency than in the earlier periods ofUfe. Syphilitic indurations or growths from the meninges may now occur ; and other attacks (often of one-sided convulsion) may be determined by various pathological changes or accidents taking place in regions of the brain where more severe lesions would give rise to hemiplegia. The pri- mary change in these cases maybe minute haemor- rhages into the brain-substance, or minute and slight softenings produced by, stopping of small vessels (embolism or thrombosis). From lesions of this kind hemiplegia and epilepsy are often more or less associated. OccasionEilly the cause may be a non-syphilitic tumour, occupying the side or base of the brain. Puerperal convulsions in the female, and maemio convulsions in both sexes, are most fre- quently met with during this period of life. During pregnancy the reflex excitability of the nervous system is often greatly increased, and in the production of puerperal convulsions some amount of uraemia also intervenes not unfre- quently. Intemperate habits, carried to excess, frequently produce fits, and so also may venereal excesses. After Middle Age (40 years and onwards). — The mobility of the nervous system gradually diminishes during this period, so that epileptic attacks commence now with still less frequency. There is, however, one period (the climacteric) in the female sex in which this mobility is temporarily increased, and in which fits lagain become more frequent, under ■ the influence of apparently slight excitingi causes. , Although fits are only very rarely liable to be induced by the sequelae of haemorrhages or of softenings of the brain, yet these events no\l' 802 grow more common as age adyances, and are therefore to an almost corresponding extent more liable to figure as causes of epileptic at- tacks. An attack of hsemorrhage or of softening may be ushered in by epileptifpTm convulsions (especially when the lesion occurs in certain parts of the brain), and in some cases such attacks may thereafter recur at irregular inter- vals. Exposure to great heat, or sunstroke, may also at this period, or earlier in life, act as the exciting cause of convulsions. Mental overwork, worry, frighc, and such-like influences, are much less likely to operate in per- Bons over 40 than in earlier life ; and the same is to be said of blows or injuries of the head, short of the most severe causing actual lesions of the brain. But the malnutrition and degeneration induced by intemperate habits may predispose to symptoms of this kind; and so also may blood-poisoning from renal disease, which is now not unfrequently present. Various organic diseases of the brain, whether principally characterized by degenerations with a process of more or less general atrophy, or with localized overgrowth of connective tissue, are also not unfrequently productive of convulsions, either in persons of middle or of advanced age. A well-marked instance of the former of these associations is to be met with in general para- lysis of the insane. Cysticerci on the s\u:face of the brain have also in some recorded in- stances been the cause of most obstinately re- curring convulsions. Lastly, it should always be borne in mind that convulsions are sometimes the result of the action of poisons of various kinds upon persons of any age. Occasionally such poisoning may be brought about by articles of diet, such as mussels or fiSi in certain states, or from poisonous mush- rooms ; whilst at other times it results from some of the well-known narcotico-irritant poisons, taken either inadvertently or purposely. Anatomicai. Oh aeactbes. — These may be said, 60 far as our present knowledge goes, to be absent. It is true that general or partial con- gestion of the brain may frequently be encoun- tered in those who die during an attack of convulsions. But this congestion is to be regarded as a result rather than as a cause of the fit. The convuls-ons are due to mere mole- cular changes in the brain, inappreciable to, or at all events unappreciated as yet by, the most skilled microscopists. When fits occur in asso- ciation with actual organic growths or other lesions of the cerebral cortex or elsewhere, such lesions may form merely the starting points for nervous impressions which travel downwards so as to upset the equilibrium of certain unstable or highly charged motor centres ; just as a simi- lar disturbance of nervous equilibrium with discharge of motor energy may result in another case from abnormal visceral impressions (in- duced it may be by indigestible matters in the intestine or by an acute disease of the lungs), or from some surface-irritation. In accordance with this point of view, such organic growths or other lesions need receive no further mention here. Those who may be inclined to think otherwise, should bear in mind the fact that ■ convulsive attacks are easy to be produced in CONVULSIONS. animals from whom the ccrelaral lemispheres have been removed. Symptoms. — The varied nature of the causes make it impossible to say anything of moderate compass concerning the premonitory signs or symptoms which may precede an outbreak of convulsions. These must necessarily vary im mensely in different cases. Some of the charac- ters of the predisposing state hare been already alluded to (p. 300). The onset is, however, often abrupt and without any distinct premonitory symptoms. With regard to the actual characters of the attack it wiU be sufficient to say here that they also vary immensely in different cases ; and as notwithstanding this great variability it is im- possible in any individual case to tell, from the nature of a first convulsive fit, whether it will form a more or less isolated attack, or whether it wiE constitute one of a subsequently recurring series, the reader may, for this part of the suh- ject, be referred to the description of the attacks given under Ehxepst. AU that is there said concerning the actual phenomena and mechanism of the attack, holds good for occasional convul- sions as well as for those which are habitual. In each we have to do with (1) a more or less distinct stage of tonic spasms, followed (2)i by one of clonic spasms, and (3) succeeded by a state of stupor. One or other of such stages, is, however, not unfrequently more or less abortive. These attacks may, at times, so rapidly follow one another as to be merged into one long series or status convulsivus, differing in no respect from the aaalogOTia status epUeptmis. Complications abd Seoiiel^. — The- compfi- cations are most various, seeing that in different cases we may have to do with irritated gums, repletion, diarrhoea, worms, or an acute specific disease ; whilst in other cases it may be with general debility and sleeplessness, with mental anxiety, puberty, or the climacteric period. Again pneumonia, renal disease, pregnancyj ovaritis, or some organic brain-disease may be the accompanying condition. The nature of the sequelae will depend princi- pally upon the frequency of the attacks and the duration of the period during which the patient has been subject to the recurrence of them, so that for this part of the subject the reader may refer to the article Epilepsy. DiAHNOsis. — There is very little difBculty in regard to the diagnosis of the affection. The differential characters of Laryngismus Stridulus are given elsewhere, and the absence of any real distinction between a fit of Eclampsia and a fit of Epilepsy has already been insisted upon. Neither of these affections can be easily con- founded with certain forms of Chorea, which occasionally present themselves in adults, with movements not unlike those of ordinary con- vulsions. The more continuous nature of the movements, and the fact that consciousness is not impaired, suffices to distinguish all forms of Chorea. The spasms of Tetanus and Hydro- phobia are also easily distinguishable from an ordinary attack of convulsions. The characteristics of hysterical convulsions will be pointed out in the article on Hysteria. The real difficulties from this point of view CONVULSIONS. 803 of diagnosis have referenca to the cause of the attack. To arrive at a decision in regard to this is often very difficult aad occasionally impossible, at all events when a patient first comes under observation. At other times, however, the indi- cations are so plain that there can be little or no difficulty. It is a question which should always be considered with the utmost care, since on the correctness of our conclusions in regard to this point the efficacy of the partieulsu line of treat- ment which we adopt must necessarily depend. Nothing is more to be deprecated than hasty jumping at conclusions, from mere routine and superficial considerations. The condition of the patient must be carefuUy examined, and the nurse, attendants, or relatives must be closely questioned in order that we may learn as much as possible as to the previous state of health of the patient, and more especially as to the time and events which immediately preceded the first outbreak of an attack of convulsions. Exami- nation and enquiries combined may convince us that the convulsions are (1) of the primary or idiopathic Variety, immediately occasioned per- haps by fright, anxiety, overwork, overmuch or indigestible food, &e. ; or we may come to the conclusion that the convulsions are (2) of the sympathetic order dependent upon pregnancy, renal disease, the onset of an acute specific fever or of pneumonia, or due to the existence of hooping cough, scarlet fever, &c Or, in the absence of reasons for placing them in either of these cate- gories, we may be forced to conclude that they are (3) symptomatic of some organic brain- disease, the nature of which must then be determined as nearly as possible, judging from the age of the patient, the mode of onset, his present state and associated conditions. In any case we may have to enquire more closely as to hereditary tendencies, or acquired predisposing causes, which sometimes reduce the nervous system to such a degree of irritability as to lead to an attack of convnisions without the aid of any obvious exciting cause. In infants or very young children such a condition of the nervous system may display itself by great rest- lessness and ^tartings at night, by the child's sleeping with half-open eyes, by drawing in of' the thumbs across the palms, by twitohings of the limbs, of the angles of the mouth, or of the facial muscles generally. In older children and in young adults the signs which most easily mark a similar below-par condition of the nervous system are twitohings of the muscles about the angle of the mouth and of the tongue (the for- mer being especially well seen when the latter organ is tremulously protruded for inspection) associated vrith debility, anorexia, partial insom- nia, and general nervousness. In nervous girls fits are induced by very slight causes about the time when the catamenia become first established. The indications for treatment must in fact vary immensely in any five consecutive cases of con- vulsions to which the practitioner may be sum- moned. Pboqnosis. — ^The possibilities under this head are at least six in number in regard to any case of convnisions: — (1) The patient may recover after having a single.fit or a batch of them within a few hours or days, and may never have another attack. (2) The patient may recover, ani thougli he or she may not have fits habitually thereafter, they may recur at prolonged intervals, when predisposing circumstances chance to be strong or are supplemented by an exciting cause of un- usual potency. Thus convulsions during teething may cease, and may not recur till the constitu- tion has been lowered by some illness years after, or when the nervous system has been rendered more irritable, as at the time when the catamenia are about to commence, especially if some slight fright should also come into operation as an exciting cause. (3) The patient may recover, though he subsequently continues to have fits either at irregular or regular intervals ; he be- comes, in short, a confirmed epileptic. (4) The convulsions may come to be followed by tempo- rary delirium or a more or less marked maniacal condition, recurring after all or some seizures. (5) The patient may recover from the Convulsive attack and may or may not have another fit, though he may remain Kemiplegic. (6) The patient may die during the attack or almost immediately afterwards, («) from the effects of it, or (A) by reason of some organic lesion by which the fit itself has been determined. Eecoveries are fortunately common, but death, especially in infants, is by no means uncommon. We possess no accurate data to enable us to assign the numerical proportion of these termi- nations to one another and to the other above- mentioned sequences. Treatment. — During the convulsion itself, whether we have to do with an infant or an adult, we must see that all clothes are thoroughly loose about the neck and chest, and the patient should be placed in the supine position with the head slightly raised. Beyond seeing that the patient does not knock or injure himself, owing to the violence of his movements, these should not be much restrained ; although efforts should always be made to prevent the tongue being bitten, by slipping the most suitable thing at hand hetween the molar teeth on one side, when the age of the patient or the character of the fit renders it likely that this event might otherwise occur. Beyond such simple measures as this, the less we do during the actual continuance of the fit the better it will probably be for the patient. We know of no rational or successful means of cutting short an ordinary attadc of con- vulsions, and in the face of such an attack we should be cautious lest evil might be done. Where we have to do with a succession of attacks quickly following one another, and which have already lasted some time, the careful administration of chloroform may be tried, as it is very serviceable in many cases when a status convidsiiMtS occurs in children or in adults — though it would not be desirable to have recourse to it in infants. Under similar circumstances, for the lattei the warm bath may be substituted, and sometimes seems to do good. On the cessation of the convulsions, or during the in tervals, the treatment to be adopted to prevent their recurrence must necessarily vary immensely according to the age of the patient, and accord- ing to the predisposing and exciting causes which appear to have been operative in inducing tlio attack. S04 CONVTJLSIONS. An oTerloaded stomach 'will call for the speedy admiuistration of an emetic, and where indiges- tible food has already passed into the intestine an enema or brisk purgative should be given. Diarrhoea must be checked, or anthelmintics administered when worms are suspected. Gums may be lanced if they seem really to need it. In many of these eases an acquired or hisreditary predisposition will have to be combated by the careful regulation of the diet, so that nutritious and easily digested food are given in place of their opposites, whilst at the same time the most suitable nervine tonics and antispasmodics are administered. For general usefulness in such cases no remedies can compare with the bromides of potassium and ammonium. As part of the specific influence which they exercise over nerve- tissue, they fortunately establish a tendency to quieter and sounder sleep, of which such patients often stand much in need. Ten-grain doses three times a day should be given at the commencement to youths or adults, and after- wards increased if necessary. Or a larger dose may be given once a day, either in the morning or at night, according to the indications in each case. Quinine or beUadonna may be often given simultaneously with great advantage. To young children or infants, the dose of the bromide must, of course, vary with their age. Valerianate of zinc and oxide of zinc are remedies of less power, though these and other drugs may be tried where bromides appear to fail. This general treatment is applicable to a large pro- portion of cases also in which in debilitated or ' nervous ' patients fits have been brought on by fright, worry, or anxiety, or by no assignable cause. Fatigue of mind and body is always to be avoided, and in those instances in which over- attention to business or over-study have been in part operative in bringing on the fits, absolute rest must form an essential part of the treatment. In girls or young women in whom fits occur at the time of the establishment of the catamenia, or where they recur in association with an irre- gular menstrual function, the general health often requires our most careful attention. The convulsions which belong to the class known as sympathetic have to be carefully con- sidered in relation to the malady of which they are the forerunners or associates. When con- vulsions precede an attack of scarlet fever or of small-pox they usually subside of themselves as the disease develops. They are, however, of much more significance when occurring during the course or towards the close of one of these maladies or during an attack of hooping cough or of croup. Our indications for treatment must then be derived in the main from the general state of the patient, and this is also eminently the ease where we have to do with ursemio con- vulsions. The treatment of symptomatic convulsions, de- pendent upon actual organic brain-disease, must also necessarily be subordinated to that appro- priate for the affection itself upon which such symptoms depend. No drug will be found more generally useful, however, than bromide of potas- Bum in ten to fifteen-grain doses for an adult (administered three times a day), in cheeking or diminishing the repetition of convulsions, in CO-OKDINATION. these cases. Sometimes the action of the bro- mide seems to be favoured by combiiiiDg it with moderate doses of digitalis, especially in those cases in which there is gseat general nervous- ness in association with a disordered caidiau rhythm. Where sounder Bleep is urgently necessary, chloral, either alone or in combination with bromide of potassium, should be given at bed-time. Tinctures of sumbul or of henbane are also at times useful adjuvants. Where we have to do with tumours of the brain, and espe- cially with syphilitic growths in the meningos, much better results are lo be hoped for from large and increasing doses of iodide of potassium, either alone or in combination with small doses of bichloride of mercury, with the administration of nutritious food and attention to the improvement of the general health.. See Bbaiit; and Sprait OoBD, Diseases of. E. CHABtxoN Bastuk. CO-OKDIlTATIOIir.— This term is used in reference to muscular movements principally. Certain parts of the nervous system have more especially to do with the calling into activity, and therefore with combining, the contractions of different muscles, both simultaneously and in succession, in the precise order in which they occur in the severalmotor acts of which we are capable. The nervous arrangements upon which these actions depend have come into being, hoth in the race and in the individual, by processes of organic growth and development pari passu with the possibility of executing these several movements. It would be wrong to expect, there- fore, that an isolated organ should exist, solely for co-ordinating muscular movements. The execution of the most habitual of these must de- pend, to a large extent, upon the activity of the ordinary motor tracts of the spinal cord and brain. The extent or precise mode in which the cerebellum intervenes in certain higher forms of co-ordination is still involved in much obscurity. That it has some share in such functions may be regarded as certain, though it probably inter- venes far less than some would have us believe, who regard the cerebellum as the organ for the co-ordination of muscular movements. Many nervous affections exist in which the co-ordination of muscular movements is more or less impaired. One of the most famihar of these is locomotor ataxy, a disease dependent upon a morbid process in the posterior columns of the cord. Sclerosis of the antero-lateral .co- lumns of the cord also not unfrequently dis- turbs_ the execution of muscular movements, especially those of the upper extremities. Cho- rea gives rise to very similar uncertainties in the execution of muscular acts. Spasms of all kinds, in short, tend to interfere with the harmony, of the muscular movements in the course of which they intervene. Stammering is an affection of this kind, implicating the muscles of articulation, and certain disturbed cardiac actions characte- rised by disordered rhythm can only be regarded as belonging to the same category. The above-mentioned are common instances of impaired co-ordination of muscular move- ments dependent upon structural or functional changes in parts of the nervous system other than the cerebellum. Certain diseases of this CO-OEDINATION. organ, however, are known to give rise to a dis- tinct formof incaj-ordination. It is characterised by a reeling, unsteady gait in walking, with legs straggling, and mostly wide apart, to which the term ' tituhation ' is commonly applied. Other kinds of inoo-ordination may hereafter be proved to depend upon diseases of the cerebellum. These are still very imperfectly recognised, and this is especially true in regard to its merely functional perturbations. Certain inco-oidinations in speech and writing are common. Instances are to be found in that use of wrong words or misapplication of terms which we meet with in aphasio and amnesic persons; also in the substitution of wrong words in the act of writing, or of wrong letters in the writing of words, when such substitution is me- chanical and unintentional — when it is wholly distinct, therefore, from mere inability to spell. These defects are inco-ordinations of a complex kind, dependent upon the perverted action of higher cerebral centres, in the same way that incoherent speech generally is dependent upon incoherent thought. There is reason to believe, indeed, that the same kind of ultimate defective nervous action which leads to inco-ordinations of movements when certain motor regions of the nervous system are affected, may, on the other hand, give rise to perverted perceptions (jlluavms) or to perverted thought {incoherence) when the disturbed nervous action occurs in other and in higher parts of the central nervous system. H. Charlton Bastian. OOFHOSIS (ma^bs, deaf). — Deafness. See Hbaking, Disorders of. OOPPBB, Foiaoning by. — Metallic copper may be regarded as innocuous when swallofred, and the recent researches of Hirt show that those who are engaged in the metallurgy and manu- facture of copper utensils are not specially liable to any diseases which can be attributed to copper as such. It is, indeed, stated that workers in copper enjoy an immunity from cholera, a conclu- sion which is based on vary insufficient premisses. It is contradicted by the occurrence of cholera among coppersmiths in Buscau in 1866, and by certain other cases of a like nature reported by Hirt. That the disease is seldom found among workers in copper is true, but that the copper has anything to do with this result is not proved. Though pure copper may be regarded as in- nocuous, it is otherwise with allays of copper, more particularly with the alloys of copper with zinc and tin, known under the names of brass and bronze respectively, and with compounds of copper with lead or arsenic. In these the inju- rious agent would appear to be the alloy, and not the copper itself. An affection of a febrile character, and known as ' brass-founder's ague,' occasionally Cjcours on fusing days, and is attri- butable to the zinc fumes which are generated by the melting process. The ialta of copper, on the other hand, are capable of causing injurious and fatal results. The more important salts, fi^m a medico-legal point of view, are the sulphate, blue vitriol, or bluestone; the acetates (basic and neutral) con- stituting artificial ver(Ugris ; and the carbonate or natural verdigris. The manufacture of ver- 20 COPPEE, POISONING BY. 806 digris is carried on to a large extent in the south of France. Plates of copper are acted on by the skins of grapes which are allowed to un- dergo the acetous fermentation. Those engaged in this industry on the whole enjoy good health, and it is only rarely that symptoms can be directly traced to the work ; and then only when through sheer carelessness and uncleanliness quantities of the salt have been ingested. It is even said that dogs eat the refuse grape-skins with- out appearing to suffer from poisonous symptoma. 1. Acute poisoning by copper. — Stmp TOMS. — The salts of copper, when taken in sufficient quantity, cause symptoms of atute poisoning, frequently terminating fatally. Twelve to fifteen grains of the acetate have been suffi- cient to kill a dog within an hour. The fatal dose in man is not quite determined ; but doses above the usual emetic dose of the sulphate (ten to fifteen grains) have caused serious symptoms, and death has resulted within four hours after swallowing some pieces of the sulphate. Half an ounce would probably cause a fatal result. The symptoms are essentially those of irritant poisoning, viz., styptic or coppery taste, constric- tion of the fauces, epigastric pain, violent vomit- ing and purging, followed by collapse and death, xisually with tetanic or convulsive symptoms. That which characterises copper-poisoning more especially, as compared with other irritants, is the frequent occurrence of jaundice. In doge copper usually causes death with symptoms of paralysis of the hinder extremities, in addition to the usual irritant symptoms. It is said also to have a paralysing action on the heart. 2. Chronic poisoning by copper. — It is generally stated that the long-continued intro- duction of copper into the system in small doses gives rise to a form of chronic poisoning known under the name of ' copper colic' Symptoms. — The symptoms are essentially those of gastro-intestinal irritation, vrith nausea or sickness and diarrhoea. They have none of the characters of colic in the sense in which the term is usually employed. The hair and the cutaneous secretions of workers in copper and brass are sometimes found of a green colour, and a line is sometimes found at the margin of the gums and teeth, variously described by authors,— Corrigan calling it purple, while Clap- ton calls it green. Though symptoms of gastro-intestinal irrita- tion, as above described, have been found among workers in copper, the question is whether they are in reality due to the copper, or merely symptoms of a not uncommon affection showing themselves among copper- workers. That copper does gain access into the system, and may be detected in the urine during life, and found in the bones after death, without the individual showing any manifest symptoms during life, seems pretty well established. But though we may regard it as certain that symptoms of copper-poisoning are more riuely found than those of lead-poisoning among those who have to deal with these metais, yet it would be a very un- warrantable conclusion, and contrary to all that we know of the action of poisons, to assert that a substance which is undoubtedly poisonous can be taken freely into thfi system with impamty. 306 COPPEE, POISONING BY. This is a point of considerable interest in refer- ence to the accidental or wilful adulteration of articles of food with copper salts. Many cases are on record of severe symptoms resulting from the use of copper utensils ip cooking, or more frequently from the storage of water or articles of food in copper vessels, especially if, the food contains oil — which, on turning rancid, dissolves the copper — or vegetable acids, or eveti large quantities of ordinary salt. Copper salts are also employed intentionally to impart a green, fresh colour to pickles and preserved vegetables, such as peas. It is as- serted that the quantity of copper necessary to produce this effect is. infinitesimal, and that no poisonous effects can be proved to have resulted even from Iqng-continued employment of these vegetables as articles of food. This is strongly maintained by M. Galippe, who has tried them on himself and family. Assuming the impossibility of proving the injurious effects of copper-tinted vegetables, the question comes to be principally a social and economic one, as to the propriety or legality of adulteration of food at all, and especially with a substance undoubtedly poi- sonous. Copper is said by some to be a natural constituent of the human body, but Boutigny furnishes strong grounds for attributing the minute quantity which may be found in the liver to accidental introduction- into the system from cooking utensils, or from fruits raised on manure containing copper. DiAQHOsis. — The greenish or bluish colour of the vomited matters, which turn bright blue on the addition of ammonia, renders the diagnosis comparatively easy. ' ■ Treatment. — In acute cases the stomach should be evacuated by encouraging vomiting, or by the stomach-pump. Albumen in some form, as milk or white-of-egg, should be giyen in order to pre- cipitate the copper. Iron filings may be given for a similar purpose. In chronic poisoning the cause should be dis- covered and removed, or the individual removed from the cause. D. Ferbier. COBK'. — Stnon. : clavus; Pr. ,C!ou, cor; Ger. Lcichdom, die Huhnerauqe. A com is a thickening of the epidermis, caused \ij undue pressure and friction, as by boots, shoes, or implements of occupation. It is usually situa- ted on a prominence, such as that of a joint, where the skin is subjected to double pressure, and is therefore unable to yield, or between the tpes. Corns are most common on the feet. A corn usually begins as a. general and uni- form thickening of the epidermis, which is termed a caUodty, {tyloma, tylosis, Schwielen). Callosities may occur on any part of the in- tegumeiit. Thus they may occupy the promi- nence of a joint, or spread over the heel or the metatarsal cushion of the foot from pressure in walkmg, or occupy the metacarpal prominences of the hand as in boatmen. The callosity i^composed of laminated epider- mis; is thickest in the centre, becoming thin towards the circumference ; and is, more or less hard and condensed, smooth and hornlike in ap- pearance, and yellowish in colour. When the irritation which gives rise to a callosity is pro- COE.ONAEY AETERIES. longed, effusion , is apt to take place beneath it, and it is raised like a blister,, the effused fluid being sometimes serous and sometimes sero- purulent. Whenever this happens, the subse- quent separation of .the, ,horny layer results in sponta,neous cure. , , , When the pressure giving rise to ^ callosity, instead of being diffused, is, concentrated on a central point, the epidermis corresponding with that point increases in thickness, by jts under surface, and forms a conical prominence ; further pressure increases, the length, and breadth of the cone, and in this way a com is established. Continued irritation enlarges the corn by hyper- plasia of epidermic cells, and its pressure produces absorption of the derma, sometimes extending to the bone itself. Not unfrequently.effusipns of serum or blood take, place beneath the comiial prominence, and, in rare instances, a bursa is fpuni between, ths corium and the joint. At a late stage of its growth the corn has the appearance of a central core — technically, thf eye of the com — surrounded by a coljar of smooth epidermis in the state of callosity,' Thecoreis a lamellated ovoid ma^s, corresponding in exter- nal figure with the cup by which it is produced; and consisting in substance of vertical oup- shaped l?,mell8e closely packed one within the other. In an old cprn the shape of- the enfu'e core is conical,, the point resting on the. sensitive skin, and the signification of. the term clofi, or naU applied to it by the French is made mani- fest. The substance of the corn resembles horn botli in colour and density, but between the toes, where moisture is generally present, it remains white and soft, like soddehed cuticle, and is thence nameji sqft-iomn, Effusioit,at,ite base is more common in the soft than in the hard corn. Treatment. — -The treatment of a coin ij, to remove its cause, namely, pressure and friction; but when this is impracticable, to equalize pres- sure, by which the corn will revert to the state of callosity. The .second indJcatimi„is.,best effected by some simple unirritating application, such as soap- or lead-plaster spread on wash- leather. , As a preliminary to this application, as much of the ha^d epidermis as possible shomd be removcid by soaking and scraping, and the core turned out with a blunt-pointed instrument The soft corn may be removed as the hard one, or by snipping, with scissors. When there is much pain and inflammation about the corn, it should be, treated by means of water-dressing. Chronic corns and caUositjes are much benefited by paint- ing with iodine liniment, and tl^e use of an un- irritating protective plaster. Erasmus Wosok. COB,H"BITIS.-!-Inflamnlation of the cornea. See Eye ani> its Appendages, DiseaseS;of. COEWPA {coriiw, a horii).' — A synonym for horns. See Horns. COROITAEY ARTEBIE3, Diseases of The diseases of the coronary arteries may be classified as folloTf s : (a) atheroma , and, calcifi- cation ; (i) aneurism ; (c) occlusion pf the orifice; (<^, thrombosis ; and (e) syphiUtic disease. , a. Atheroma and oalcifloation of the; coro- nary arteries are ordinary, but by no means cob- COEONAEY AETERIES. stant sequelse of similar changes in the root of the aorta. The disease may be general, affecting both vessels equally or unequally ; or it may be limited to one of them, or even to a primary branch of either; and may lead to fatty degeneration or fibroid change of the corresponding substance of the heart. The experiments of Mr. Erichsen and M. Schiff have proved that the nutrition of the heart in health depends upon a free coronary circulation, and pathology has confirmed this con- clusion. Dr. Quain found the coronary arteries diseased or obstructed in 13 out of 33 cases of fatty degeneration of the heart, and in one of these' cases, the trunks of both vessels being healthy, a calcified coronary branch led to the only portion of the heart exhibiting fatty.change. Of 65 cases of fatty degeneration of the heart collated by the author from the Transactions of the London Pathological Society, 21 exhi- bited atheromatous or calcific change of the coronary arteries. In 10 of these death oc- curred by rupture of the left ventricle, in 1 by rupture of the right ventricle, and in 2 by rup- ture of the septum veutriculorum, the coronary branch leading to the seat of rupture having been, in every instance, in a more advanced state of disease than the other portions of the vessel. From the foregoing statistics it wduld appear, that whilst fatty degeneration of the heart may exist independently of disease of the coronary arteries, the latter condition may be legarded as the immediate cause of fatty change in the heart, in the proportion of about 38 per cent, of all cases. STMPTOMa AND SiGKS. — ^Thcre are none which are peculiar to this disease ; those which exist being due to the consecutive changes in the substance of the heart. The doctrine formerly held, that calcification of the coronary arteries was the cause of angina pectoris, is no longer tenable. In an example of this disease in its most typical form, eventuating in death, which recently came under the. writer's notice, the coronary arteries were found, on examination, to be perfectly sound. 6. Aneurism of the coronary arteries is of rare occurrence. It is usually preceded by athero- matous or calcific" changes in the coats of the vessels, and may, ■ therefore, be regarded as a disease of mid(Ue or advanced age. Br. Gee has, however, published an example of coronary aneurism in which the patient was a boy of only seven years. Stmptoms and Signs. — There is no positive indication of coronary aneurism during life. When the termination is fatal, as it usnaUy'is, death occurs by haemorrhage into the psricardium from rupture of the sac. c. Oooluslon of the orifices of the coronary arteries has been met with only in connection with calcific changes in the root of the aorta, a partially detached calcareous plate overlying the orifice of either vessel (both are rarely affected), and partially or completely shutting off the cir- culation. Tliere are no symptoms distinct from those of the principal disease. d. Thrombosis of the coronary arteries is a frequent result of disease in the coats of these vessels; and, owing to their small size, complete blocking and arrest of circulation through them COEPOEA QUADRIGEMINA. 307 are the ordinary consequences of this accident. The heart-substance, depending upon the oc- cluded vessel for its vascular supply, quickly undergoes the atrophic changes of fibroid or'fatty degeneration. Special symptoms are entirely wanting. Disease or obstruction of the coronary arteries, with the ordinary consequences — fatty degenera- tion of the heart, and anaamia with white soften- ing of the brain — are the conditions usually found in cases of permanently slow pulse. «. Syphilitic disease of the coronary arteries has been recorded in a few instances, but its identi- fication depended entirely up6n the history and the concomitant symptoms, the deposit being histolo- gically indistinguishable from ordinary atherbma. Thomas Hatdew. ■ OOBPOBA AMYLAOE A (gorpus, a body ; and amyhim, starch). — These minute bodies, which were described in thi? country by Dr. Quain and Dr, Hughes Bennett in the 2nd and 3rd vols, of tho Transactioiis of the Pathological Society, were thus named by Yjrchow. They are generally only visible with the aid of the microscope, but , sometimes are large enough to be seen by the naked eye, and now and .then attain some size. Usually they ^e round or oval, and pre- sent a concentric, laininated arrangement, which is made more apparent by the action of acetic acid. They often have. a yellowish tinge. In ap- pearance corpora amylacea somewhat resemble starch-granules, and they are tinged brown or bluish by the action of iodine upon them.. These bodies were formerly supposed to be composed of stanch, and hence their name. This is not t\e case, hqwever, and thejr actual chemical com- position is not clearly known ; i it probably differs in different structures. Bodies, resembling corpora amylacea in appearance and arrangement have been found in various parts, but they have attracted most attention iij Qpnnexion. with the nerve-centres, being particularly .observed when these are the seat of atrophy or degeneration ; they are.ajsp seen ir^ the choroid plexus, . Fbsdbbick T. Bobebts. COKPOBA QtrADBIGEIillTA, Lesions of. — The facts of comparative anatomy and experimental physiology tend to show that the corpora quadrigeihina {corpora bigemina'oi optic lobes of the lower vertebrates) are in rela- >tion not only with vision and iirido-motor co ordination, but also with those functions which are, to a large extent, independent of the cerebral hemispheres, viz., equilibration and locomotor co-ordination. The fects of human pathology, though not opposed to these data, cannot be made the basis of very precise concliisions as to the diagnostic indications of disease of these ganglia, as it is exceedingly rare to find disease liniited to this region anatomically or functionally. The corpora quadrigemina are, however, not unfrequently involved in lesions which invade neighbouring parts, such as meningitis — simple and tubercular, tumours, especially of the pineal gland and middle lobe of the cere- bellum, &o. ; but disease strictly limited to the corpora quadrigemina, such as local softening, ip extremely rare, and haemorrhage is unknown. 308 COEPOEA QTJADEIGEMINA. It is a fact agreed on by all experimenters that when the anterior tubercles, -which are more especially connected -with the optic tracts, are destroyed, Tision is abolished, and that if the lesion is unilateral, the blindness occurs on the side opposite the lesion. These phenomena in animals are in accordance -with -what has been observed in man. Dr. Bastian has recorded a case of total blindness, in ■which the cause proved to be softening limited to the anterior tubercles of the corpora quadri- gemma, {Paralysis from Brain Disease, p. 116). It has been found experimentally in animals, and also in man, that atrophy of the opposite tubercle ensues when the eye has been destroyed. Irido-motor action is also paralysed by destruc- tion of the corpora quadiigemina, a result -which, however, is stated not to occur unless the injury is more than superficial and implicates the oculo- motor nuclei. Disturbances of equilibration and co-ordina- tion also result from lesion of the corpora quad- rigemina. These are attributed to lesion of the subjacent tracts, and, according to Lussana and Lemoigne, more particularly to lesion of the subjacent superior cerebellar peduncle. For his o-wn part, the -writer thinks that all attempts at differentiation are pure hypotheses, and from the nature of the question must remain so. But, from whatever cause, there is no doubt that the disturbances alluded to do occur. Irritation of the corpora quadrigemina on one side causes dilatation of the pupils and a hemi- opisthotonus of the opposite side, which becomes general if the irritation is prolonged or bilateral, the head being retracted and the legs extended, trismus also being very marked. According to Lussana and Lemoigne unilateral lesion of the corpora quadrigemima causes an incurration of the trunk and gyration to the side of lesion. This would agree -with the effects of irritation, being naturally a reversal of the phenomena. Clinical illustrations of these facts in the lower animals are difficult to find, for the reasons above mentioned ; but a case reported by Dr. I>aSS.n(Clin.Soo.Trans^ vol. ix., p. 187), whidithe writer had an opportunity of seeing and examin- ing post mortem, is important in this relation. This was a_ case of tumour of the pineal gland; which, besides passing forward into the third ventricle, pushed underneath the aqueduct of Sylvius, stretching and causing atrophy of the. corpora quadrigemina. The symptoms, in addi- tion to those of cerebral tumour, -viz., violent occipital headache and double optic neuritis, were double vision followed by loss of sight, ver- tigo, specially marked when the eyes were open, staggering gait, and tendency to retraction of the head and rigidity of the dorsal muscles. The pupils were large and sluggish. These symptoms, to a certain extent, resemble those caused by tumour in the middle lobe of the cere- bellum, and it is a question how far these latter may be due to mechanical irritation of these ganglia. But we may infer that such a combi- nation of symptoms as the above points to lesion of the corpora quadrigemina, or of the middle lobe of the cerebellum, though we cannot be certain of absolute limitation of the lesion. Naturally tho same secondary affection of the CORPUS STEIATUM, LESIONS OF. functions of the cerebral hemispheres occurs from tumours situated in this region, as in casea of tumours of the middle cerebellar lobe. Pressure on the veins of Galen leads to dropsy of the cerebral ventricles, and its oonsequenccB on the cerebral circulation and functions. D. Fbeeiee. OORPUIiElTOll {corpus, a body, and leiiim, thick). — An undue accumulation of fat in the body. See Obesity. COBPtrSCLB {cor^uscvilum, a little body). — In physiology and pathology this word ia generally used as synonymous with cell. See Cmi. OOBPtrS STKIATUM, Lesions of.— The corpus striatum of English anatomy and pa- thology comprises various structures which have received special names, viz. : ^'inwolMsca'aialus, or intra-ventricular nucleus, which is exposed to view by laying open the lateral ventricle ; the nuclevs lentwalaris, or extra-ventricular nudoM, consisting of three divisions, and subjacent to the convolutions of the Island of Eeil ; together ■with part of the internal capsule, or peduncular expansion, which forms part of the 'projection system' between the cortex and cms cerebri. This differentiation is considered necessaryi as it is believed that the effects of lesion of the corpus striatum -will differ according to the part involved, although up to the present it cannot bs said that this has been conclusively established. This is not to be wondered at considering the excessive rarity of lesions which have an exact anatomical and functional circumscription. Physiological experiment, while thoroughly in harmony -with clinical and pathological obser- vations respecting the effects of lesion' of tho corpus striatum, has not succeeded in defining the functions of its several parts, if such differ- entiation exists, with any degree of precision. The statements made by some physiologists on the point, do not seem to the -writer to rest -on any satisfactory basis. The corpus striatum is especially liable to lesion from embolism or rupture of its blood- vessels. These are furnished principally by the middle cerebral artery, which in the first part of its course sends off numerous straight twigs, which sink into the anterior perforated space, and supply this ganglion and the adjacent part of the optic thalamus. Owing to their position, and direction as regards tho main cur- rent, they are easily ruptured or blocked up, and owing to their being of the nature of ' end arteries,' and almost destitute of auastomoseswith other cerebral arteries, embolism rapidly leads to softening of tho regions which they nourish. Symptoms. — The symptoms of lesion of tho corpus striatum may be divided into three groups or stages. First stage. — This includes certain symptoms which are more or less transient, and depend chiefly on the suddenness of the lesion and functional disturbance of other parts. To the latter belong the symptoms usually accompanying an apoplectic seizure (apoplexy), as also the loss or diminution of sensation onthe opposite side of the body, which sometimes oc- curs in consequence of pressure on, or functional interference with, the sensory tracts of the in- CORPUS STRIATUM, LESIONS OF, 300 temal capsule by effusion into the corpua stria- tum. The symptoms due to the suddenness of the lesion of the corpus striatum as such, are complete paralysis of every voluntary movement oa the opposite side of the body, occasionally varied by con^nilsive spsms of the paralysed side, and conjugate deviation of the head and eyes towards the sound side. This latter symp- tom is due to the centres for the head and eyes of the opposite hemisphere suddenly losing their antagonists. The temperature of the paralysed side is as a rule higher than that of the sound side; The total paralysis and flaccidity of the opposite side of the body, and conjugate de- viation of the head and eyes, are transient symptoms, lasting from a few hours to a day 01 two. Second stage. — This stage includes those symptoms which continue for a variable period, suter those depending on the suddenness and disturbing effect of the lesion have passed off. They constitute the common type of hemiplegia or paralysis of voluntary motion on the side opposite the lesion. The face, arm, and leg, and to a certain extent the thoracic and abdo- minal muscles on the one side of the body, are affected. The paralysis does not affect all these parts equally. As a general rule it may be stated that those movements are most affected which are most independent of those of the opposite side, and which are most complex and delicate. Hence the movements of the hand and arm are more affected than those of the face or leg, owing to the fact that these latter are more commonly exercised in associated or alternating action with those of the other side. The facial paralysis is most marked in the lower facial re- gion. The orbicularis palpebrarum is more or less paretic, but never paralysed to the extent which occursinBell's or true facial paralysis, depending en lesion of the portio dura. The angle of the mouth on the paralysed side hangs lower, and the tongue deviates slightly to the paralysed side. The weakness of the facial muscles is best brought out when the patient smiles or tries to whistle. The face then becomes drawn to the sound side. While some volitional cori- trol may have been acquired over the leg, the hand and arm remain perfectly motionless. In the process of recovery, the leg recovers before the arm, and as a rule the recovery pro- ceeds from the proximal to the distal end of the limb, the shoulder and hip movements being regained before those of the hand or foot. The flexors regain their power before the extensors. ' The sensibility 'of the paralysed parts is un- impaired; the superficial reflexes are diminished, the deep (tendon) reflexes increased. The faiadio contractility of the muscles is unimpaired, occasionally rather increased than diminished. The muscles do not undergo atrophy except by disuse. The temperature of the paralysed limbs, which at first is usually increased, is generally found to be lower than that of the sound side, to the • extent of a degree, more or less. Recovery may take place from all the symp^ tcmis of this stage, within a period varying from weeks to months, or the patient may pass into the third stage. Third stage. — The special symptoms of this . stage are the ocourrenoo of what is termed ' late rigidity ' in the paralysed limbs, a condition of evil import. This rigidity shows itself most frequently in the arm, but it is common enough in both limbs. The rigidity affects the flexors more particularly, and causes the limb to as^ sume a position in which the flexors predomi- nate. It is variable in degree and at first is capable of being overcome. At first also, it is remittent, tending to give way when the patient abstains from volitional efforts or from excite- ment, and seems almost gone on waking from sleep or when the patient yawns or stretches himself. gradually it assumes a more intense foim; and the limb becomes permanently fixed and rigid. After death, this condition is found to coin- cide with descending sclerosis of the motor tracts of the brain and spinal cord. The dege- neration proceeds from the seat of lesion down- wards through the crus, pons, pyramid of the same side, and then across to the posterior part of the lateral column of the spinal cord on the paralysed side. Frequently also, a similar track of degeneration is found on the inner aspect of the anterior column of the spinal cord, on the same side as the brain-lesion (Charcot, Tiirck, &o). Even during the rigid stage, there is, as a, rule, no trophic degeneration of the muscles or annihilation of faradic contractility, though the muscles waste from disuse unless artificially stimulated. But in some rare instances as Charcot has shown, the secondary degeneration invades the anterior cornua of the spinal cord, in which case amyotrophy or trophic degenera- tion of the muscles ensues. There is no recovery from this condition. Variations and complications. — Though gene- ral hemiplegia of the opposite side, without affection of sensation, is the type of disease of the corpus striatum, certain variations and complications have been observed, some of which still require elucidation. When sensation is permanently affected along with voluntary motion, we have reason to re- gard the lesion as not confined to the corpus striatum, but as implicating also the posterior part of the internal capsule and the thalamus, an occurrence by no means rare. When the lesion affects only the grey matter of the nu- cleus oaudatus, it is said that the hemiplegia is as a rule comparatively slight and transitory. Similar affection of the nucleus lenticularis is said to produce more marked paralysis than that caused by affection of the nucleus caudatus, but also not of a permanent kind. When, how- ever, the lesion causes rupture of the anterior two-thirds of the internal capsule, the hemi- plegia is most marked and most enduring. It is this lesion only which gives rise to secondary degeneration of the motor tracts and permanent rigidity. Cases are on record in which lesions of the corpus striatum have given rise, not to general hemiplegia of the opposite side, but to mono- 810 0OEPU3 STEIATITM, LESIONS OF. plegia, such as paralysis of the face or of one or other limb. We cannot yet say whether the lesions in these cases affected specially differ- entiated centres or medullary fibres, but that such may be the case is not impossible, though the subject requires iuTestigation. Cases are also on record of paralysis occur- ring on the same side of the body as the lesion. The real existence and explanation of such ex- ceptional occurrences are still sfubjvdiee, and though various explanations may be suggested, it is well to wait for further instances, carefully investigated by accurate modern methods, before pronouncing definitively on the Question, Treatment. — It is unnecessary to discuss the treatment of lesions of the corpus striatum, as this is considered under the head of the various diseases cif the Brain. D. !F£krier. COEKELATIOIT. — This term is used in medicine almost exclusively in reference to the aetiology of disease, and in this relation princi- pally in regard to the zjraiotie diseases. The term ' correlation of the physical forces ' may be taken as implying that the several forces are capable of being converted into or of giving place to one another when they are permitted to act under certain conditions, and that they are all related to a common cause. It is very much the same idea that is implied by the term ' Cor- relation of the Zymotic Diseases/ a subject which has recently been discussed in a separate work by A. "Wolff. It is contended that the several contagious diseases of a general type (the exanthemata) do not, necessarily and in all cases, reproduce their like; but that occasionally, the contagious par- ticles thrown off from the same sick person suf- fering from some one of the diseases {e.g. scar- latina) may suffice to engender one or more different kinds of disease, according to the mode in which this matter operates — that is according as it may be swallowed,' taken into the system through the pulmonary surface, or through some other mucous-membrane or skin abrasion. These diseases are said to be correlated, therefore, on account of this assumed relation to a common cause — a specific contagium. According to this notion the seat of primary action and the con- stitutional condition of the patient are factors which largely influence the form of disease which will ultimately manifest itself as a result of the contact of any given contagium. This view has at present scarcely passed beyond the stage of an ingenious speculation — ^though it is One which is by no means unworthy of further attention. Diseases may be said to be correlated also when they are severally related to the same cause acting with different degrees of intensity. Thus it is held by some epidemiologists that the plague is only a malignant form of typhus ; that-yellow fever is due to a more intense form or action of the same poison as suffices at other times to engender intermittent or remittent fever ; and that summer diarrhcea, cholerine, and cholera are also but different manifestations of one common though variable cause. Similarly it is held by many surgeons that ordinary surgical fever, pysemia, and septicasmia COUGH. are correlated effects. They maintain that the appearance of one or other of these morbid states after a surgical operation is dependent in the main upon differences in the constitutional condition of their patients, and,tooreover, that these forms of disease are further linked to one another by numerous intermediate states. This point of view has been both strengthened and extended of late, by' some of the experimental researches of Dr. Burdon Sanderson. He found that the subcutaneous injection of different por- tions of the same inflammatory product, exe- cuted at the same time, would often produce quite different effects upon different anilhals of the same species. At one time a typical sep- ticaemia proved rapidly fatal, at another a slower pyaemic process was established, whifet in a tlhird animal the still more chronic process o{ so-called tuberculosis was set up. Here we get out of the region of speculation into that of fact. The term correlation is only ' applicable to communicable diseases, otherwise its leading signification, viz. convertibility, could not Be fulfilled. Hence it is that though very many diseases may arise from the operation upon dif- ferent individuals of some common cause (such as exposure to cold), the maladies which may result from such a cause no one would think nf speaking of as correlated. H. Charlton Bastun. COEEOSIVE StTBLIMATE, Poisoning by. See Mebcuey, Poisoning by. CORTZA (K(}p«fo, a running froni the head], — A synonym for nasal catarrh. &c Ca'taeeh. ; COUaH.— Stnon. : Tussis; 'Ei. Toux; Ger. Description. — The aot of coughing consists in one or more abrupt forcible expirations^ accom- panied by contraction qf the glgttis,<^ :First a deep inspiration is taken, the glottis isiclosedifor a moment, and then it is opened by the preBSBTSipf the air forced out by the combined action of ii^ thoracic and abdominal expiratory muscles. Witjb the air thus suddenly expelled, any foreign matter that may be in the larynx or bronchi is driven into the pharynx or the mouth. . ^TioLOOT. — The .immediate cause of coiigh is the presence of an irritant, mechanical: or sympa; thetio, affecting the surface of the air-tubes or the nerves that supply them, and it is the objecj of the cough to remove this source of irritation. The sensibility of the respiratory surfaces is greatest at the commencement — the glottis being an ever-watchful janitor. It may beincreased by congestion or inflammation, or by thfljcontinued act of coughing. Even the mere inhalation of eool or dry air may, in asthma or bronchial conges- tion, be sufficient to excite cough. The result of the irritation is to increase the natural secre- tion, and to alter its characters (see Exfeotoea- tion). Cough may be due to numerous refies causes, such as gastric irritation, .saivdisorder, i or aneuriemal ■ or other pressure on the vagus, re- current, or sympathetic nerves. The act maj also be caused by a longuTula or enlarged tonsil; • a granular state of the pharyngeal or laryngeal mucous membrane;: polypi or othej! foreign COUGH. Txxiiea in the larynx, trachea, or even in the ex- ternal auditory meatus ; various aftections of the hronchial tubes — e.g., undue dryness, hypersemia, alteration in the quality or quantity of the bron- chial secretion, or inflammatory affectipns; in- flammation of the lungf or {ileura,; or tubercle, cancer, or other growths in or near the lung. SiAQKOsis. — Cough is not a disease to be treated, but a symptom to be traced to its source. An inspection of the pharynx and larynx and a physical examination of the chest will generally snfftce to detect the cause. The character of the cough is often quite Tpathogilomonic — e.g., the ' -whoop ' of whooping cough ; the ' bark ' of hysteria ; the catchihg, paiffful cough of pleurisy; the slight 'hack' of early phthisis, and the equally distinctive cough of advanced-phthisis with laryngeal ulceration ; the loud clanging coxigh due to pressure on the trachea or laryngeal nerves ; the spaBinodio, suffocative cough of asthma. The 'tightness' or ' looseness' of cough, indi- cating the absence or presence of secretion, is a valuable guide in diagnosis and treatment. ' The absence of cough is no proof of the absence of serious lesion : while the presence of a few granulations in the lung is often productive of in- cessant and uncontrollable cough, long-continued destructive disease may exist without it. ■ Tebatkent. — Before prescribing for a cough it is of course essenti&l to ascertain its cause ; and the simplest and most innocuous remedies should be first used. The routine treatment of cough by sedatives is as injurious as is their use in diarrhoea. The secretions which ought to be removed are thus, in either case, locked up,- and the irritation, which would have been transient, becomes established. If the tonsils are found much enlarged, or the uvula pendulous and irritating the ' epiglottis, caustics or the guillotine will remove the evil. If a granular state of the pharyngeal mem- brane, dependent on torpid or engorged abdomi- nal viscera, gout, or hepatic obstruction, exists, it may be treated by local astringents and general deobstruents. A lax or congested state of the laryngeal membrane, due to overwork of voice, or the un* due direction of attention to the vocal apparatus (clergyman's sore-throat)j is best treated, accord- ing to the writer's! experience) by the local ap- plication of iodine dissolved in spirit and oUve oil. Undue dryness, simple hypersemia, or hyper- esthesia of tie respiratory mucous tract, may often be relieved by the act of sipping and slowly swallowing cold water, or the i decoction of Iceland moss, fruit lozenges, gum arable, liquorice, or linseed tea* Sucking ice or in- haling steam is very often aU that is needed. In the early stage of catarrhal sore-throat, chlorate of potash in crystal, or in the form of lozenge, should not be neglected. The use of glycerine of tannin, or nitrate of silver dis- solved in glycerine (half a drachm to one ounce) is of more service lin relaxed throat than alum or tannin gargle ; indeed, the free use of -well-se- lected lozenges has rendered the employment of gargles well-nigh obsolete. The former can be constantly, the latter but seldom applied. Medicinal treatmmt. — If it ,is dtesired to in- COUNTER-IREITANTS. 311 crease the fluidity of the secretion, squill or ipecacuanha may be used, or better still, tartar emetic in small doses, which is best given in effervescence with ammonia and citric acid. It must not be forgotten that syrups and nausea- ting expectorants are apt to do harm by enfeeb- ling or disturbing digestion. Tincture of aconite in three-drop doses is often of value in allaying irritable cough, especially when fever is present. Gelseminum is the novel remedy for the same purpose. Of the direct sedatives, morphia is the most valuable ; it proves of service in very small doses, iVgr. in a lozenge being often ado- quate. Conium, with or without morphia, suite some persons ; hydrocyanic acid still more ; and Indian hemp is also of value. The bro-^ mides, in combination with chloral, have recently gained great repute j the latter should be given with caution. The power of the bromide of ammonium in allaying spasmodic cough is re- markable.- An emetic of ipecacuanha, sulphate of zinc, 01 mjistard may be useful in relieving cough, by expelling secretion when this has ac- cumulated in large quantity. If cough causes vomiting, food should be taken in small quaati- ties, fluids should be limited, and a little capsicum or sj*iced braiidy ' stays the stomach.' ^eternal applieations.^-The use of counter- irritants must not be neglected. In the inflam- matory stage of bronchitis, for instance, linseed and mustard poultices, and in the later stages, iodine or croton oil are of great use. The ap- plication of a small blister or vesicating fluid is a remedy not to be forgotten in some cases. Inhalations. — Infusion of hops as an inhalation is a useful calmative; iodine is indicated in re- laxed conditions in strumous subjects. Chloro- form (10 to 15 minims) mixed with Eau do Cologne, and inhaled from a handkerchief, is use- ful in other cases. By means of the spray-inhaler, many non- volatile preparations may be applied t;b the respiratory passages. A solution of carbon- ate of soda is very useful in liquefying tenacious secretion:. < Tannio'aoid, alum,iperchloride of iron, and nitrate of silver, are aU valuable. Of seda- tives, henbane, conium, camphor ; and of anti- septics, sulphurous and carbolic acids are ser- viceable as inhalants. In chronic granular disease of the pharyngeal and laryngeal mucous membrsines, ■ the i. sulphurous waters of Aix-la- Chapelle,' Aix-les-Bains, and St. Saveur in the Pyrenees, when inhaled in an atomised state, are of distinct service. Patients may be thus taught how to cough : — Tiy to suppress the inclination, until the secre- tion that causes the cough is within reach, then take a deep, and deliberate inspiration, and the accumulated phlegm is removed at a singl6.eJfort. By inhaling steam from a hot sponge' or basin of boiling water on first waking from sleep, the inspissated secretion, which is apt to be difficult to move, may be easily loosened and expelled. An ipecacuanha lozenge may serve a similar purpose. E. S-jthes Thompson. COU1J-TEK.IH-DI0ATIO1J-. &e CoNiBA- UrDICATION. COXrilTEB - IKEITAITTS. — The term counter-irritation imphes any irritation arti- ficially established with a view to diminish, S12 COUNTEE-IEEITANTS. eonnteraot, or remove certain morbid processeB which may be going on in a more or lees remote part of the system. The substances employed in establishing this state are called counter-irri- tants, and may be classified as follows, according to degree of action : — 1. Rubefacients ; 2. Epi- spastics, vesicants, or blistering agents ; 3. Pus- tulants. Although some therapeutists have of late been disposed to question the value of counter-irri- tants, on the theoretical ground of inability to explain their mode of action, yet there is not wanting evidence, both from clinical observation and physiological experiment, that irritation in one part of the body may afFeet the functions and nutrition of other parts. That stimulation of the vessels of the surface can influence de- cidedly the circulation of deeper parts has been demonstrated by Dr. Brown-S4quard : for he found that irritation of the skin of the back, over the kidneys, caused a contraction of the arteries supplying those organs. From this ex- periment we can understand how a blister may relieve a sudden internal congestion in the lungs or brain, and how it may act in restoring tone to dilated and paralysed capillaries, Eevulsion and derivation are both examples of counter-irritation. In the first, the induced mor- bid action is set up in a part remote from the primary disease, as when mustard poultices are applied to the feet in an attack of apoplexy ; in the second, derivative action is set up in the neighbourhood of the primary malady, as when a blister is placed on the back of the neck for the relief of cerebral disorder. Rubefacients. — Action. — These remedies, applied to the skin, produce local warmth and redness from increased fiow of blood in the cutaneous vessels. The local hypersemia tlius induced subsides gradually on ceasing to employ the rubefacient; but sometimes, when the action of this has been prolonged, the epidermis may peel off, and more or less local soreness remain. Rubefacients are usually quick in action ; their local after-effects are trifiing; and they may, therefore, be applied without injury over a large extent of surface. Enumeration and AppUcation. — Examples of rubefacients are found in Ammonia and Ammo- niacal Liniments or Embrocations; Mustard Wasters and Liniment; Volatile Oil of Mustard ; Oils of Turpentine and Cajuput; and Iodine. Hot water is at times applied on a sponge or flannel to produce a speedy counter-irritant and derivative effect in relieving sudden internal con- gestion and spasm, as in the early stage of croup, laryngitis, and laryngismus stridulus. The Cata- plasma Sinapis, or mustard poultice, is a useful and rapidly-acting rubefacient in inflammation, spasm, and neuralgic pain. Dr. Garrod recom- mends a very useful sinapism, made by mixing 10 minims of volatile oil of mustard with 1 oz. of spirit of camphor, and sprinkling this on impermeable piline. EigoUot's mustard leaves, and the Charta Sinapis or mustard-paper of the Pharmacopoeia, applied to the skin, produce a speedy rubefaotion of the surface. Vinegar BhoiJld not be added to mustard poultices; but by mixing some oil of turpentine or a little powdered capsicum in a mustard poultice, its rapidity of action as a stimulant and rubefacient can be greatly increased. Where,, on the other hand, a gentle stimulation with warmth and moisture to the surface are desired, as in some cases of pneumonia, a linseed-mcal poultice may be used, with its surface sprinkled lightly over with mustard-meal. Generally twenty minutes is as long as an ordinary mustard poultice can be safely borne on the skin. In persons whp have a very delicate skin, a layer or two of muslin should be placed between the mustard application and the surface of the body. In applying mustard poultices to those who are unconscious of ,pain, caution is necessary, for it has happened that the poaltice being left on for a long time has pro- duced dangerous ulceration and sloughing of the surface. A mustard foot-bath is At times em- ' ployed with a view to a revulsive and counter- irritant effect. To prepare a mustard bath,; two tablespoonfuls or more of mustard should bo tied in a cloth, and agitated well with cold water ; then hot water may be added to make the bath. It is found by experiment that cold watei; extracts the active principle or volatile oil of mustard far better than very hot water does. Uses. — Rubefacients are used in chronic in- flammation and irritation of the mucous sur- faces, as in bronchitis, and irritation about the air-passages. Troublesome cough, in cases of phthisis, is often relieved by applying tincture of iodine, or acetic acid and turpentine liniment, to the chest. Rubefacients are of service in removing lingering irritation about a joint, their use also tending to promote the absorption of chronic thickening or effusion in the joint ; but friction with a rubefacient liniment' over a joint must not be employed till all active in- flammatory action has entirely ceased. Various degrees of persistent counter-irritation may 'be maintained by applying, after the skin hnsbeen well cleansed with soap and water, the Emplas- trum Picis or Emplastrum Calefaciens of the Pharmacopoeia. A mustard plaster- applied to the nape of the neck has proved useful in cases of irritable brain with sleeplessness. The same application made to the foot or great toe is a valuable revulsive where gout attacks more important organs. A mustard plaster has the advantage over a blister in rapidity of rubefa- cient action ; and, from the sharp pain caused, the mustard plaster is preferable when it is a matter of moment to rouse one who is in a state of lethargy or torpor from narcotic poisoning liy opium, or alcohol, or from coma in the course of a fever. Where we wish to exercise a prolonged action over chronic inflammation in an organ, we should use a blister rather than a sinapism. Veaioauts, Epispastics, or Blistering Agents. — Action. — A blister acts primarily as a rubefacient and powerful stimulant to the cutaneous vessels. The papillse of the skin be- come reddened and raised ; minute vesicles soon appear on these elevations ; and these, gradually coalescing, form a bleb, or large vesicle, contain- ing an albumino-fibrinous fluid. Enumeration and Application. The agent most commonly employed for blistering purposes is Cantharis or Spanish fly, in the several prC' parations to be found in the Pharmacopoeia ; but there are other agentsthat have been used fora COUfifTER-IREITANTS. gimilar object. Glacial Acetic Acid applied to tlie skin produces intense redness and pain, -with rapid vesication, but its action may extend deeply as a caustic, and cause a troublesome sore. Liquor Ammouis dropped on a piece of lint, applied to the skin, and coTored -with a wa.toh-glasB, very soon causes redness and rapid resication in most persons. This is a good way of raising a blister when it is desired to apply powdered morphia endermically to relieve severe pain. The application of blisters should not be made directly over an inflamed part. There is some evidence to show that a strong stimulus applied very near an inflamed organ may increase the paralytic dilatation of its capiUarios, and so add to the disease. Blisters should not be applied where the skin is loose, nor over any prominence of bone, nor to the breast during pregnancy. It should moreover be borne in mind that the cantharidine of a blister may be absorbed by the skin, and act on the kidneys, producing strangury and bloody urine. This accident may be obviated by sprinkling powdered camphor over the blister before .placing it on the skin, or a thin piece of silver paper may be interposed. In persons of feeble vitality, a blister left on too long time has been known to induce dangerous sloughing. When vesication is specially desired, there is no need to leave the blister on for twelve hours or more, for it may be removed at the end of six or eight hours, and a warm linseed poultice applied. If the blister be opened, which is best done by pricking the most dependent part with a needle, sweet oil and cotton-wool is the best dre_ssing. The practice of maintaining a blister as a running sore or exutoire, by applying irri- tating ointments, is not often resorted to now. The process causes great pain aud exhaustion of the system, and is one rather of depletion than of counter-irritation. In the case of chil- dren, blisters should be used with caution, being kept on till the skin is well reddened, when they should be replaced by a poultice. It is also a good plan not to open the blister, as the effused serum forms the best dressing for the excoriated surface, and by following this plan the child is saved much worry and pain. Uses. — In its primary action a blister acts as a local stimulant, but when it remains on long enough to produce extensive vesication and dis- charge of serum, it acts as a depletive and de- pressing agent. This primary and secondary action of blisters has been much insisted on by the late Dr. Graves of Dublin, who found great benefit in cases of fever with apathy and pros- tration from ■t'b.e application oi flying blisters to, various parts of the surface.; Thus, a blister over the prsecordial region, kept on for about one hour, and then removed, was observed to rouse and stimulate a flagging heart. In other cases the flying blister might be placed at the chest or back, or else behind the head on the neck. Care should be taken not to leave the blister on long enough to cause vesication, and the size of the blister should, be fairly large. Vesication by a blister is , of service in many brain-afifestiDna attended with congestion and tendency to serous effusion, such as in the chro- ftic stages of hydrocephalus, and non-tubercular 31S meningitis. In hysterical paralysis narrow strips of blister placed completely round the affected limb have proved curative. A strip round the throat may cure nervous aphonia. A strip of blister one inch wide will sometimes stay the spread of erysipelas along a surface. In cases of pleuritic or pericarditie effusion the repeated application of blisters to the chest-wall is of manifest advantage. In effusions into joints (hydrarthrosis) blisters aid absorption ; and it has seemed to the writer that absorbent reme- dies, such as iodide of potassium, often begin to do good as soon as a blister appears to have once set the absorptive process in action. • .In the joint-affections of acute rheumatism, ' the jalister treatment' has attracted notice. Armlets and wristlets of blister-plaster are applied close to the inflamed joints during, the fever, and the serous discharge from the blister is kept up by means of linseed-meal poultices. In the obstinate acid vomiting of gouty pa- tients, a blister over the epigaistrium often gives relief. Some' forms of neuralgia, as for example pleurodynia, may yield to a blister over the seat of the pain. At times obstinate pleurodynia, or mastodynia, can be relieved by flying blisters applied in the vertebral groove on the affected side, where $ tender spot can often be detected on pressure. Blisters should be avoided in cases of renal and vesical inflammation, as the absorption of the cantharidine may increase the mischief. Coimter-irritatiou by heat. — The skin can be rapidly blistered by applying a hammer or a small flat iron heated in a spirit-lamp or boiling water. The skin is tapped for a few seconds with the hammer, just to induce redness of the part. In some forms of rheumatism, neuralgia, and spinal weakness, this practice has been fol- lowed by satisfactory results. Vesication of the skin by iha ferrvm candens, or hot iron, has been used in chronic joint-disease, Moxas are used for the purpose of causing severe counter-irritation. European moxas are made either with cotton wool soaked in solution of nitrate of potash, or of the pith of the sun- flower, which , naturally contains this salt. A wet rag is placed on the skin ; in the centre of this is a hole in which the lighted moxa is placed, which gradually bums down to the skin and pro- duces an eschar which iujdue time, separates by suppuration.. In spinal affections, and in some forms of paralysis of the sensory and motor nerves, moxas are said to have done good ; but their application is very painful, and now they are seldom employed. Pustulauts. — Action. — The agents belonging to this class of counter-irritants produce a pus- tular eruption on the part of the skin to which they are applied. Enumeration and Application.-r-Among pustu- lanta may be placed croton oil, tartarated anti- mony, and strong solution of nitrate of silver. "When croton oil is applied to the pkin, it acts as an intense .irritant, producing an eruption which is at first papular but very soon becomes pustu- lar. Tartarated antimony in the form of oint- ment, or in hot aqueous solution, is a powerful counter-irritant, producing pustules whieh re- semble those of variola. When applied thus it may, by becoming absorbed, induce symptoms of 314 CO UNTER-IEEITANTS. gastro-enteritis. It should not bo applied to parts usually Uttcovered, as the pustules leave marks behind. them; and under all circumstaneeB the remedy, being a painful one, must bei usedi with caution. Strong solution of nitrate of silver will produce pustulation, but it is seldom employefi for this purpose. Issues have long been used as counter-ir- ritants. An issue is formed by placing on the skin a piece of adhesive plaster, in a hole in the centre of which a fragment of caustic potash is inserted. The caustic causes an eschar, and when this has come away an issue-pea is > placed in the cavity left by the eschar ; this pea acts as a foreign body, and keeps up suppuration. One drachm of pus may be discharged daily by an issue ; more than this is too great a drain on the system. An issue requires to be dressed daily, and when it has been long open and run- ning it must not be healed too suddenly. Issues over the spine have been found useful in chronic spinal disease ; and in some chronic brain-afiec- tious, with hypersemia and' congestive tendency, an issue in the back of the neck or in the arm is frequently of service. Setons. — A seton is made by passing a nar- row-bladed knife under a fold of skin and then carrying a few silk threads through the incision by means of a probe or long needle. The threads remaining in the wound prevent it from healing, and maintain a free purulent discharge. Setons are used for the same purposes as issues, and they have proved useful in certain intractable forms of headache — the seton being inserted in the skin of the neck. Setons have been used in cases iOf cystic bronchocele with thickened walls ; in chronic inflammation of the bladder ; in many chronic affections of the uterus ; in various chronic skin-diseases of an obstinate character ; in chronic inflammations of the eye, and ulcera- tions of the cornea ; and in the early stage's of pulmonary phthisis. In acute aifections issues and setons are never employed, and they should not be placed over any part where there is much movement, as a troublesome sore may be the result. It is neces- sary to bear in mind that issues, setons, and pustulants are, like blisters, when kept on long enough to induce serous discharge, of the unture of evacuants. They carry off nutrient material from the blood, and therefore are more or less depressing and exhausting to the system, and their repeated or protracted employment will tend to induce the irritative fever of debility. John C. Thobowgood. COUP DE SOLEIL (Fr).— A synonym for sunstroke. Sec Sohsteokb. CO"W-POX. 8ee Vaccinia. OOXAIiGUA (coxa, the hip, and 8X701, pain). — ^Pain in the hip-joint. See Joints, Dis- eases of. OKACKED-METAL or CBAOKED-POT SOTJND {Bruit depot fele). A peculiar sound elicited by percussion, and resembling that emitted on striking a broken jar or a metallic See Physical Examination. CRAMP. — This name is applied to certain painful varieties of tonic spasm. In its most! CRETINISM. • familiar form it affects the calves, of 1 the legs, coming on principally at jnighl^j on the occasion of some slight movement of "these parts. The affected muscles, mostly on one side, coitraot withiBuch energy as. to give, rise to a board-like rigidity, togetherwith sensations of an agonising character. The attack rarely lasts more than a minute or two, though; it may more or less speedily recur. It isrperhaps best cut shortby'a vigorous but steady voluntary: contraction of .(^j opposing extensor muscles of the foot. ; Where it is more obstinate than usual, firm pressure around the thigh or upon the great sciatic nerve, some- times gives relief. Cramp is often associated with some irritation of the stomach or of the intestines, especially in children or delicate nervous persons. In this way it is produced not infrequenfiywhea arsenic in medicinal doses has been continued for some time, and is beginning to exert a slightly poisonous effect upon the system. In a more general form it often occurs, to a marked extent, in cholera, Otlier forms of painful spasm are by no means common, if we except colic. See also SpASU. H. Chakiton Basjun. CBAWIOTABES.— &« SKUtt, Diseases oif. CRBPITAWT (crepiio, 1 make a noise).— When applied to a body, this word signifies that it is capable of yielding the sensation or sound of crepitation. It is also associated with a r41e, to indicate a peculiar character which it possesses, See Physical Examination. OREPITATIOH' (crepito,! make a noise), — A sensation or sound of crackling. It maybe observed in morbid states of the bones, joints, or subcutaneous tissue; but the term is mole frequently applied to a physical sign connected with the lungs. See Physical Examination.- ' CEETIKTISM (cretm, chalk).^SYN0N. : Lat, Cretinismus; Er. Cretinisme; Grer. Cretinismiii-, Ital. Cretinismo. Definition. — A condition of idiocy arising from endemic causes, associated with imperfect development and deformity of the whole body, varying however in degree. This condition of physical and mental de- generacy is not limited to any nationality. It obtains in the great mountain-chains of Europe, Asia, and America. In Europe it is met with in the valleys of Switzerland, Savoy,: and Piedmont; and it abounds in the neighbourhood of Salzburg, Styria, and the Tyrol. It is less frequently met with in the Pyrenees and in the valleys of the Auvergne in Prance. Even in England it has been met with in various parts, among others in the dales between Lancashire and Yorkshire; Although more frequently met with in valleys, it is not unknown on plains which are subject to inundations. Description. — The degrees of cretinism are numerous. A residence in one of the valleys where this affection exists, enables one to teaoe the various steps of- degeneracy, commencing with those who are taking part in the -industrial life of the valley, down to the helpless indivi- duals who are leading only a vegetative exist- ence. The typical cretin presents a marked physical OEETINISM. conformation. He is stunted in growth, rarely reaching five feet in height. His akin is of a tawny yellowish hue, thickened and wrinkled ; and looks as if too large for the body. There is also a great increase of Subcutaneous areolar tissue. His tongue, large and thick, with hypertrophied papilla, always displays lessened power of co-ordination ; and often hangs from the mouth.' The moutli is partly open, margined •by thick fissured lips, and with the saliva running over the chin. The face is large ; the lower jaw is drooping, and its angle obtuse. The eyes are often affected by strabismus, obliquely placed, and Small ; and the lids are commonly puffy; The belly is pendulous from the laxness of the skin. The Ibwer limbs are generally short and deformed , andthe gait is waddling. The head ie deformed, the forehead retreating, the top flat, and the occi- pital region ill-developed. The cranium is bra- chycephalic. The nose is broad and flattened. Puberty is often delayed to the twentieth year. The mammse in the female are large and pendu- lous ; the same remark applies to the genitals in the male. The intellectual faculties are imper- fectly developed. The cretin is often unable to speak, and ■ his 'hearing is frequently defective. The aifection is usualiy associated with more or less enlaigement of the thyroid gland. His viability is low, few living beyond thirty years of age. The sexual functions are abnormal ; mastur- bation is frequent ; and the subjects of cretinism are often impotent. MxiOLOGrt.' — The conditions for the development of cretinism are hereditary predisposition ; the action of deteriorating influences on the parents, such asunwholesome dwellings and non-nutritions diet; aud accidental causes operating on the infant during the period when its physical and intellec- tual life are developing. The last-named causes areatmospheirio andpossiblygeological conditions, peculiar to special localities. Humidity of the soil and air in valleys where there is little interchange of the atmosphere, and the existence of magnesian limestone in the soil, are probably the most potent factors. Cretinism is not met with as an endemic disease on elevated plateaux, nor in cold countries whero sudden changes of temperature are uncommon, Groitre is a frequent accompani- ment of cretinism, and would appear to be de- veloped under the same conditions. The cases of cretinism met with in England present features which are indicative of a scrofulous Crigin. There is a condition of idiocy associated with arrest of growth and development at the period of first dentition, not unfrequently met with' in Eugbud, which has been tertnei'' Sporadic Cre- tinrnn. Some of these cases have been traced to alcoholism on the part of the progenitors, and are usually associated with an absence or atrophy of the thyroid body; There is reason to believe that children become cretinoid when taken to reside, at the period of their early development, in localities where the disease is markedly endemic. There are numerous, well- attested instances of healthy women living during their pregnancy in cretinic districts bringing forth cretinoid children,' who removing from such localities, propagate healthy children. By far, however, the greater number of cretins arrive atl ' their Mpless condition by successive CEIMINAL lEEESPONSIBILITy. 815 stops of degeneracy in their ancestors. It has been thought that cretinism was due to pre- mature ossification of the cranial sutures, es- pecially of the spheno-basilar suture; and that this was caused by drinking water largely charged with lime. It is impossible, however, to regard this premature ossification, when it does occur, as other than one of the outcomes of the malady and not its cause. Moreover there are numer- ous examples whero the synostosis is deferred instead of being premature. Akatomioal Ohaeactees, — Pathological ana- tomy shows that the bones of the cranial vault are thickened and without diploB. The basilar groove is generally wanting. The foramina for the passage of arteries and nerves are somewhat smaller than natural. The occipital fOssse are flatter than ususd, as if the flattening had re- sulted from a compression of the cranium from above downwards. Every variety of deformity of ■ the cranium is met with of the braehyoephalic type. The brain is usually small, unsymmetrical, pale, and infiltrated with serum. Premature synosltosis is occasionally met with at the spheno-basilao; suture, and with it a rectangular form of the base of the skull : this,- however, can- not be regarded as a constant condition. DiAGNOSis.^-The diagnosis of cretinism may be made in childhood, from the slowness of the de- velopment of the body, the stupid expression, the postponement in the evolution of the teeth, and of the ossification of the fontanelles and sutures, the tawny yellow colour of the skin, the thick and goitrous neck, the slavering, and the delay of speech and of' walking': Tjreatment. — This consists in removing the child as early as possible from the circumstances which have produced the disease. He should be taken to a locality Where the soil is dry and porous, and should have frequent baths with friction to the surface of the body. The diet should be of the most nutritious kind — a diet into 'which animal food largely enters. Theadministration of cod-liver oil and of the lacto-phosphate of lime and iron is indicated. Eariy education should be com- menced as to habits of cleanliness, followed by systematio physical exerciso of the various muscles. All intellectual advancement must be sought for through the improvement in every way of his physical condition. The lower animal life may thus be supplemented', if earnest efforts are used, by increased capacity for rational enjoyment, and a more or less useful existence, i J. Langdon Dovtn. OEIMINAIi IBBESPOU-SIBILITT.— Historical Summary.' — A medical opinion as to the condition of an accused person is often necessary in order to determine whether he or she can be held accountable for criminal acts. Such an opinion generally depends on the pre- sence or absence of insanity, or on the con- nection which may be traced between this mental condition and the act in question. In the article on legal Insanity it 'is explained that it is only -within a comparatively recent period i that insanity has been admitted as an excuse for crime, except in those comparatively rare cases in which, as Justice Tracey expressed it in 1723, a person does not know what he is doing, ' no 816 more than an infant, a brute, or a wild beast.' See Insani'xt, Legal. This -view fairly represents the state of public and of legal opinion until tbe later years of the eighteenth century. The subsequent enlightenment of the public mind did not receive juristic expression until the trial of Hadfleld in 1800, when Erskine first enunciated the doctrine, that 'delusion where there is no frenzy or raving madness is the true character' of such insanity as im- plies irresponsibility. The most important case in the history of this question was that of Bel- lingham, who was executed in 1812 for shoot- ing Mr. Spencer Perceval. In this case Lord Chief Justice Mansfield said, that if a person labouring under mental derangement were cap- able in other respects of distinguishing right from wrong, ' he could not be excused for any act of atrocity which he might commit.' ' It must be proved beyond all doubt,' he added, ' that at the time he committed the atrocious act he did not con- sider that murder was a crime against the laws of God and nature.' The trial of MacNaughton in 1843 for the murder of Mr. Drummond led to the most authoritative statement of the law which has ever been obtained in this country. MacNaughton was acquitted on Chief Justice Tindal's direction that the point for the jury to consider was whether ' at the time the act was committed ' the accused ' had that competent use of his understanding as that he knew that he was doing by the very act itself a wicked and a wrong thing.' The general application of this doctrine would have greatly enlarged the area of irresponsibility, and its enunciation at that time produced considerable surprise' and even consternation. The matter was indeed regarded as so urgent that the House of Lords imme- diately ordered a series of questions to be laid before the fifteen judges with the view of settling the state of the law. In the answers to these questions it was in substance laid down, that to entitle an accused party to acquittal on the ground of insanity it is necessary that he be of diseased mind, and at the time he committed the act not conscious of right or wrong ; or, that ho be under some delusion which made him regard the act as right. But this statement has been far from effecting a final settlement of the ques- tion. Most writers on medical jurisprudence have insisted that the real criterion of responsibility is the freedom of the will, or the power of the individual to control his actions. 'This has been more or less advocated by Esquirol, Marc, Eay, Pagan, Jamieson, Mittermaier, and Von Krafit- Ebing, Esquirol dwells' strongly on the impor- tance of the freedom of the will. Eay includes it in the comprehensive statement which has received the approval of so many medical jurists. ' Liberty of will and action,' he says, ' is abso- lutely essential to criminal responsibility, unless the constraint upon either is the natural and well-known result of immoral or illegal conduct. Culpability supposes not only a clear perception of the consequences of criminal acts, but the liberty unembarrassed by disease of the active powers which nature has given us, of pursuing that course which is the result of the free choice of the intellectual faculties.' Pagan observes CRIMtNAL IREESPONSIBILITy. that the 'loss of control over our actions, which insanity implies, is that which renders the nets which are committed during its continuance undeserving of punishment.' Jamieson puts the question : ' Had the lunatic at the time of com- mitting the deed a knowledge that it was cri- minal, and such a control over his actions a^g ought, if it existed, to have hindered hun from committing it.' Dr. Taylor says :' The power which is most manifestly deficient in the insaiie is generally the controlling power of the will'; and he expresses the opinion that ' we have hero a fair criterion on which responsibility or irre- sponsibility may be tested.' Dr. Bucknill's view is substantially the same. ' Eesponsibility,' he says, ' depends upon power, not upon know- ledge, stiE less upon feeling. A man is respon- sible to do that which he can do, not that ■which he feels or knows it right to do. If a man is reduced under thraldom to passion by disease of the brain he loses moral freedom and respon- sibility, although his knowledge of right and wrong may remain intact.' The latest German code puts responsibility upon the same basis, ' An act is not punishable,' according to it, ' when the person at the time of doing it was in a state of unconsciousness ; or of disease of the mind, whereby free volition was prevented.' Mittermaier and Von Krafit-Ebing sanction the attempt to render the meaning of ' free volition ' more definite by describing it aa made up of libertas Judidi and libertas C(»m2>2, freedom of judgment and freedom of choice. Casper some- what obscurely defines criminal respon'sibilityas ' the psychological possibility of the efficacy of the penal code.' Mr. Balfour Browne, a recent writer, gives as the best definition ' a knowledge that certain acts are permitted by law, and that certain acts are contrary to law, and, combined with this knowledge, the power to appreciate and be moved by the ordinary motives which influ- ence the actions of mankind.' Dr. Guy thinks that every person who is insane must be regarded as wholly irresponsible, and that the law of Eng- land ought to be assimilated to that of France in the declaration that : ' II n'y a ni crime ni dilit lorsque le privenu etait en itat de dimence an temps de Taction." Mr. Warren,' on the other hand, suggests that a person should not be held irresponsible unless he were as ' unconscious of his act as a baby.* Dr. Maudsley and others hold that the determination of responsibihty in cases where insanity is alleged depends on whether a connection can or cannot be traced between existing disease and the act. Insanity has been pleaded as an excuse for acts of theft ; but such cases are rare, and never occur except where the social position of the accused adds importance to the decision. Indeed it may almost be' said that the plea is never raised, except in order to avoid capital punish- ment. Hence it is, that in the discussions which have arisen the question has been intimately associated with the law of murder and homicide. A special inquiry into the state of this law by a committee of the House of Commons' has conse- quently, ^ven occasion to the enunciation of im- portant views as to the legal relations of insanity ■ Eeport of Select Committee of the Honso of CommonJ on the Homicide Law Amendment Bill, July 21, 1874, CEIMINAL IREESPONSIBILITY. 317 and responsibility. Evidanoe was furnished to the Committee by Lord Chief Justice Cockbum, Baron Bramwell, Mr, Justice (now Lord) Black- burn, and , Sir James Ktz- James Stephen. The immediate objectqf the Committee was to examine a bill drawn by Sir James Stephen for the codi- fication of the law of homicide. In the clause of the bin which deals with the relations of disease and responsibility, homicide is stated to be ' not oriminal if the person by whom it is committed is at the time when ie commits it prevents by any disease affecting his mind — (a) from know- ing the nature of the act done by him, (i) from knowing that it is forbidden by law, (c) from knowing that it is morally wrong, or (d) from controlling his own conduct.' But it is stated to be ' criminal, although the mind of the person committing it is affected by disease, if such dis- ease does not in fact produce one of the effects aforesaid in reference to the act by which death is caused, or if the inability to control his con- duct is not produced exclusively by such dis- ease.' It was, however,, proposed in the bill that, ' if a person is proved to have been labour- ing under any insane delusion at the time when he committed the homicide, it shall be presnmed, unless the contrary appears or is proved, that he did not possess the degree of knowledge or self- control hereinbefore specified.' That is to say, where delusion exists, the burden of proving moral capacity would be shifted, the prosecutor having to prove its existence, instead of the ac- cused having to prove its absence. The opinions elicited during the enquiry showed that the law is regarded by legal authorities as being at pre- sent too uncertain in its operation, and as falling to recognise some of the most important elements in the question. The4ivergent character of the recommendations which were made showed, how- ever, that legal opinion is much divided not only as to the proper relations of insanity and crime, but also as to the essential elements of respon- sibility. In the meantime, therefore, the state- ments of the fifteen judges after the MacKaughton case remain the chief exposition of the English law where insanity is pleaded in excuse for crime. Present ttate of the question, — It is necessary, in order to justly appreciate the present aspect ii>f the subject, thus to trace its more recent his- tory, and it would be useful, did space per- mit, to present an estimate of the comparative value of the several tests or criteria which have been proposed for the determination of cases in which insanity has been alleged. These criteria may be broadly summarised in the following six propositions. According to one ^iew a person should be held irresponsible for an act if at the time of conmiittiug it (1) he laboured under insanity of any kind or degree ; according to another, if (2) he laboured under delusion; or (3) if ho was ignorant of right and wrong ; or (4) had not power to appreciate and be moved by ordinary motives ; or (5) had lost the controlling power of the will ; or (6) if the act is traceable to, or its nature has been determined by mental disease affecting the agent.. The last of these views is the only one to which fatal objection may not be raised both on the theoretical and practical sides. The others are all too vague to be of much advan- tage ; and they rather tend to introduce new difficulties than to remove those already existing. The proposition therefore which seems to ap- proach nearest to a solution of the difficulty is that irresponsibility must bo admitted whenever the act is traceable to, or its nature is deter- mined by mental disease affecting the agent. It will of course be understood that under such a rule the term ' mental disease ' must be held to include both congenital and acquired disorders : arrest of development being as much a morbid condition as functional or strnctural change. This view of the subject may not be ultimately accepted in the precise terms of the proposition here given ; but the principle on which it rests seems to afford the only safe basis upon which we can go. As has already been shown, it has not hitherto been regarded in this light by the majority of the judges ; but there have been in- dications of late years that judicial views are tending in that direction. The late Lord Wen- sleydale and others have given sanction to the principle in theirjudicial statements. And the present lord Justice-General of Scotland (Inglis) gave definite expression to it in one case (^Brown, Sept, 1866). He told the jury that the main question was ' whether the prisoner was in such a state of insanity at the time, as not to be responsible for the act which he had committed' ; and in order to constitute such insanity he said that 'it must be clearly made out that at the time of committing the act the prisoner was labouring under mental disease in the proper sense of the term, and that that mental disease was the cause of the act.' In America the doc- trine has been frequently acknowledged, but never more fblly and tersely than by Judge Doe, of New Hampshire {State v. Pike), who compre- hensively defined the medical relations of both criminal irresponsibility and civil incapacity, when he stated that 'a product of mental disease is neither a contract, a will, nor a crime.' One im- portant point is to prevent persons from being punished for actions which are the direct outcome of pathological processes. But it is of equal im- portance to avoid the adoption of a principle which would make the existence of slight mental irregularities incompatible with responsibility. There does not appear to be any danger of this in acting on the principle which is here enunciated. For it lies in the very nature of the cases in which the doctrine could be applied, that the condition to which it is proposed that irresponsibility should be attached must be one which is known to exhibit itself in acts of serious and even criminal character. If the trained observer of disease is able to recognise in an act — which is ordinarily followed by severe punishment — a du:ect result or a characteristic feature of a morbid process, of the existence of which there may otherwise be sufficient proof, the question of responsibility cannot present any serious diffi- culty. It may admit of doubt whether a person is responsible for not controlling his actions, or for not knowing right from wrong, or even in some oases for the harbouring of a delusion. But once let it be proved that an act is the natural result of a disease under which a person is known to labour, and the question must be 118 CKIMINAL IRRESPONSIBILITY. practically removed from the field of discnsEion, Before, however, the princ^le can be accepted as fully satisfactory, it is necessary to enquire whether its application would permit insane persons to be held responsible who ought not to be so considered. In other 'words, are there states of insanity in ■which a person is irrespon- siblp for acts to which he haS' not been predis- posed or impelled by the insanity? It is per- ha,ps impossible to give such an answer to this question as would be both definite and complete • but for practical puiposes we' think it may be answered in the negative. Where the insanity is of such a nature that it does not modify the whole conducti we believe it will be found in practice necessary to admit the existence of re- sponsibility for acts where there is no demon- strable connection between them and the mental disease. The insane persons who on this prin- ciple might be held responsible, would' be found solely- among those whose irresponsibility could only be admitted after very searching enqiiiry, and whose insanity was of that kind and degree wlM(Sh has often been declared by medical writers to be consistent with responsibility. It is not to be supposed that under this rule difficulties would cease. It would often be hard to show in cases of actual disease that there was good' reason for believing in its existence, or that it wa-s really contributory to the act committed. This, however, would not result from any defect in. the principle, but from that imperfection of our knowledge which renders the perfect appli- cation of any principle impossible. Let the task of the medical witness be limited to the demon- stration of facts indicative of disease and its consequences, and he will at least be acting quite within his special province and might expect that reasonable weight would be attached to his opinion. And if juries were instructed that the law does not hold a person responsible for acts committed under the influence of disease, it is scarcely c'onceivable that anyone would be found guilty where good cause had been shown even for the reasonable supposition of such an influr enoe. = Whatever may be the view ultima,tely adapted, it would seem to be in every way de- sirable that . the attention of the m£dical expert should be confined to the elucidation of thd medical f^ets, and that hei should not be required to deal with questions which are legal and ab- stract, and in no way specially medical. The condition known &&^dvmmsh^ res/ponsibility has not been alluded to in this article. ^ It is only indirectly recognised by British law, and there- fore, though much is to be said in favour of its recognition, it is unnecessary to deal with the subject here. John Sibbald. OKISIS (xplais, a decision, a turn). — Crisis is a term applied to the rapid defervescence of an acute febrile disease. It has wandered some- what from its original meaning, which was 'judgment,' — primarily an operation in the mind of the observer, but reflected upon the pheno- mena observed. The converse term, employed to designate a gradual subsidence of fever, is lysis. Crisis formed at one time the basis of an im- portant medical doctrine. Certain days from the onset of the disease on which the crisis oom- CEISIS. monly occurred were considered to be propitioua The seventh day was especially favourable, while the sixth was the most unfavourable'; speaki'iig generally, the odd numbers or the multiples of 7 were propitious, and even numbers and such odd numbers as stood near multiples of 7, such as 19, were unpropitious. The preparation also for a crisis was indicated and the critical day foretold' by remissions perceptible some days previously. The whole morbid process of fever was lepresented as a process of elaboration by which a materies inorH was prepared f6r expul- sion, and an essential feature of the crisis was a critical evacuation, by means of which this -vfas eliminated. The doctrine of crisis and even of critical days was- not pure imagination or superstition, but was founded originally on lareful observation, In times when nothing was known of the orgarao lesiotis which give rise to fever,and in countries where a large proportion- of the diseases were of a malarious origin, it would aflford data for prbg^' nosis and conduce- to appropriate treatment; and at the present day in hot climates a crisis is anxiously looked for in febrile attacks on ai given day, and, as is well- known, a critical fall of temperature and improvement in the general symptoms precede in pneumonia improvement in the physical signs. In order to constitute a true crisis the defer- vescence should occupy less than forty-eight houi'S, and it often takes- place in S. much shorter time. The fall of temperature should be accom- panied by a corresponding reduction in the fre- quency of the pulse, and should coincide with a feeling of relief aad a return of strength, the skin will be warm and softj the tongtie moist, and there Will be indications of -reviving appetite ; there may or may not be a critical evacuation, but the secretions will become, more natural in amount and character. This favourable mode of -termination of an acute febrile disease is more common than is usually supposed. The circumstances -onder which it is most likely to occur- are when- the attack begins abruptly &nd the temperature rises rapidly, the natural course of the disease being short and not attended -with organic lesions, such as will df themselves keep up fevei'; After twenty-one days, termination by crisis is not to be expected. The more marked the onset, aS( for example, by a definite rigor; the more rapid the rise of temperature and the greater the height to which it reaches, the greater the pro- bability of an early critical termination. OoonHEENOE.-^The diseases in which the con- ditions favouring a crisis are realisedv and in which this mode of termination is observed, belong to various classes'. Among the spemjui fevers, eruptive and con- tinued, it occurs frequently in variola, but i-n severe cases it is interfered -with by the febrile disturbance excited by the eruption. In measles it is very common : in scarlet-fever a true crisis is seen only in mild cases, though the onset of this disease is peculiarly abrupt. The mode of termination of typhus is essentially critical, but as a rule the crisis is not sharp. Relapsing fever aflfords the best examples of crisis, which is moreover attended by a critical evacuation in CRISIS, the form of profuae perspiration, the temperature sometimes falling 1 0° F. in aa many hours, and the patient passing from a state of extreme suffer- ing and oppression to almost perfect ease and comfoi*. In enteric fevei lysis is' the mode of termination. ' . . . , Remittent fevers often present crises, -which may be true and ourAtive, or false and illusive; and the sttn-fever and common continued fever of hot climates, and tropical diseases generally, have a tendency to fever running high 'very early and breaking abruptly at a critical period. In this country fiverish odds, attacking the throat or taking the form of influenza or catarrh, often terminate critically in three or four days. Erysipelas may so end, but at a later and less dffinite period. The sharp /eiriZe attacks which sometimes occur after oMldUrth often exhibit a v^ry decided crisis. In pneumonia the natural tenhination is by a. -well-marked crisis, which may take place as early as the' fifth day, or be deferred to the ninth, after vrhich a critical ter- mination is not to be expected, and the sus- picibn may be entertained that the case is not one of frank pneumonia, the prognosis becoming grave. As has' been already stated, the general improvement precedes the indications by phy- sical signs of resolation in the_ inflamed _ lung. Pleurisy is said also to terminate critically, but it is not in the same definite way as pneu- monia. The eriUcal evcmuatidns which entered into the original notion of a crisis are really a com- mon attendant. The most common is a profuse warm perspittition, which may occur whatever the disease may be. Occasionally the evacua- tion is a copious flow of urine, or it may take the form of diarrhoea. Epistaxis or hsemor- Jlioidal flux is a more rare and doubtful critical evacuation. A common critical phenomenon is a prolonged, sound, and refreshing sleep. ' -The question whether or not a favourable crisis' affects the odd rather than the even days has been a frequent subject of dispute, and it still remains undecided. It is not, however, of any importance ; but auotheij point handed doW with the doctrine is worthy of attention, namely, that ihdidations of an approaching crisis are often given two or three days beforehand in Might remission's of fever. By the presence or "absehce of such remissions at a certain period of the attack, or by a continuous rise- of tem- perature -where a reinission might be expected, important prognostic information may be atf- forded and indications for treatment obtained. Theeapeutic Indications. — The Biain thera- peutic ded-iiation froin a study of crisis! as a ter- ihination of acute disease is, that we should not hastily interfere with the'reactionfe by which the Bystem ' adjusts itself to altered 'conditions or meets the incidence of the causes of such dis- ease, but contribute to their completion. We do not assume the- existence of 'a ms medieatrix tending invariably to the restoration of health ; but we must 'recognise the power inherent in a living organism to respond by internal changes to external influences, and to regain the balance when this has been disturbed. In this process a certain' cycle of changes must be gone through, and the gr^at opportunity for treatment of an CROUP. 319 active kind, should any be required, arises when ' the course, direction, and probable duration of these changes are known, and when agencies can be brought to bear at a given moment, which will contribute to bring about the appropriate critical evacuation or a critical sleep, through which a return to a normal condition would naturally be effected. WnxiAM H. Beoadbhnt. OKITIOAIi. — ^Having relation to a crisis. See Cuisis. OKOUP. — Definition. — Croup is a word which, in accordance with its etymologyj origi- nally meant stvidulous breatMng, a symptom, therefore, of laryngitis stridulosa, laryngismus stridulus, oedema of the glottis, laryngo- tracheal diphtheria, and other affections which perma- nently or spasmodically contract the chink of the glottis; It was imported from the Scottish ver- nacular into medical nomenclature by Dr. Francis Home, of Edinburgh, in 1765, when he published a tract of 60 sparsely printed pages, entitled An Inguiry into the Nature, Came, and Ome of the Croup. It has since drifted into very strange and very different meanings. 'In France^' to quote the Dictionary of Littri and Robin, ' it is a term now generally reserved for tracheal diphtheria : ' in Germany, it is applied to membranous deposits on the internal sUfface of organs, such expres- sions as ' croup of the uterus ' and ' croup of the intestine ' being in current use : in Great Britaiin it is used, as employed by Home, Cheyne, and their fbllowers, to designate a disease which they believe to be distinctive and separate, but which is declared by an increasing number of British physicians, the foEowers of Bretonneau, to be a mere literary composite of diseases pathologically different from' one another. In a general -way, the question — ^What is croup f — has now been answered. It is necessary, however, still farther to expWn the position which ' croup ' at present holds in the literature and Science of British medieine. •_ In 1826 Bretonneau of Tours, bythe publica- tion of his work entitled Becherches sur Vln- patMaiion Spiciale du JUsu Muqneux, en, paf- tiatiliBr sur ' la Mphthirite, created the name, and first pointed out, in that and subsequent ■writings, the true pathology of diphtheria. He did not, however, describe a new disease. He only disentangled it from other diseases in which it had been mixed up in description. Modern literary research has shown that diphtheria has at intervals prevailed, under various names, in many countries, from the earliest medico-histo- rical times. Home, in his little monograph, de- scribes only eight cases ; and of theSe, all of which he calls by the name of ' croup,' five are manifestly tracheal diphtheria, and three are eases of laryngitis. As no false membrane was seen in the three cases of laryngitis, he concluded that it had been absorbed, or that' the treatment had prevented its formation ! For a long period his successors, British and foreign, continued to make similar mistakes ; and indeed tiU Breton- neau published the result of his clinical study, the error now adverted to was 'universally ac- cepted as the trnth. In 1801, Dr. John Cheyne of Edinburgh published his Essay on Oynanohf 820 ' Tranhealis, or Croup, a pamphlet of 80 pages illustrated by five excellent plates, the work of the illustrious Charles Bell. Cheyne, like Home, has confounded together infantile laryngitis and infantile tracheal diphtheria in one disease, which he calls ' cynanche trachealis or croup.' He at- tributes the recoveries from the former to the energy of the bleeding and purging; and the deaths from the latter to the imperfect adoption of that treatment. Dr. Cheyne's essay contains only ten cases. In the history of the five which terminated in recovery, nothing is said of false- membranes having been seen ; and in four of the five which terminated in death, there was found false-membrane, which is well depicted by Charles Bell in the coloured plates. If the account now given of the constantly quoted, and often mis- quoted, little tracts be correct, where is the foun- dation for the statement reiterated up to the hour at which we write by a succession of British authors, that the said writings of Home and Cheyne contain the description of an individual disease — croup — possessing essentially different features from the laryngeal and tracheal diph- theria of Bretonneau ? It must be admitted that, while the inference to which the preceding remarks are intended to lead is in accordance with the views of some eminent British physicians, it is at variance vrith the teaching of others who claim respectful atten- tion. Dr. Charles West, in ' the edition of his Lectures on the Diseases of Infancy and Child^ hood, published in 1874, when discussing 'Diph- theria or Angina Maligna,' says ; — ' I have come to the conclusion which I long hesitated to adoptj that what differences soever exist between croup and diphtheria, they must be sought elsewhere than in the pathological changes observable in the respiratory organs. The mere extent of false- membrane in the air-passages certainly affords no ground for a distinction between the two affections, though I think it is more common to find the falss-mambrane reaching to the tertiary bronchi in diphtheria than in primary croup,' In these sentences he intimates his belief in a non- diphtheritic membranous croup — a disease which many maintain has no existence, except in books. In the same work, in the lecture on croup, he says : — ' It can scarcely be necessary to tell any of you that croup is the £nglish name for the disease designated by scientific writers cy- nanche trachealis or ct/nanohe larynffea. It con- sists in inflammation, generally of a highly acute character, of the trachea or larynx, or both, which terminates in the majority of cases in the exuda- tion of &lse-inembrane, more or less abundantly, upon the affected surface.' — (Lecture xxiii, p. 390, 6th edition, London, 1874.) The only case of croup given by Dr. West in the lecture is one which, if Bretonneau's teaching be correct, is a typical case of diphtheria affecting the air-pas- sages. The case and the sentence by which it is introduced, are subjoined :— ' The danger,' says Dr. West, ' of being lulled into security by the apparent improvement of a child who has been attacked by croup, is so serious that before proceeding to consider the treatment of the disease, I will relate to you a case by way of caution. On June 25, a little girl, four years old. became hoarse and lost her appetite, though CEOUP. she did not appear otherwise ill. On the 27th, she seemed less well, and in the night was very restless, and had difficulty of breathing. On the 28th, respiration was more difficult, and though she had but little cough, she seemed sometimes in danger of choking. In the night a croupy sound accompanied her breathing, and violent attacks of dyspnoea were of frequent occurrence. On the 29th, she was taken to a surgeon, who gave her some medicine, after each dose of which she was sick; and this sickness was followed by much relief and by an almost complete cessation of the croupy sound. This improvement was thought to have continued during the 30th; the child slept quietly during the night, and was considered so much better by her parents that she was brought by them to the Children's Hosr pital at 9 a.m. on July 1, As. she lay in the lap in a sitting position, her countenance was pale and livid, her respiration was sibilant, her sur- face cool, her pulse very frequent and feeble ; but she did not appear to be in any of the distress usual in the advanced stages of croup. At 9 a.m. she was admitted; at 6 p.m. she died, thougltiic| great distress nor violent struggle, for brestH preceded her death. The extensive deposit flf false-membrane in the trachea and bronchi showed that in spite of her apparent amendment for a season, disease must all the time have been advancing, unsuspected by her friends, overlooked even by her medical attendants.' This case, given by Dr. West as a case of the disease which he calls croup in contradistinction to diphtheria, will be regarded by the medical profession in France, and by all other follQvei;B of Bretonneau, as a typical and graphically de- scribed example of diphtheria implicating the air-passages. . They will say that it was typical in its manner of invasion, in its course and dura- tion, in its being relieved by emetics, in the anaes- thesia and asphyxia proclaimed by quietude and the pale lividity of countenance observed nine hours before death; and finally, that it was typical in the extensive deposit of false-membrane in the trachea and bronchi. In illustration of the remarks made at the beginning of this article on the meanings of the term croup, it is well to remind the reader that Dr. West's case, now quoted, will be called crotip by French physicians, for they reserve that name for the manifestation of diphtheria in the au- JJTIOI.OGT. — The disease which Home, Cheyne, West, Sansom, and many other older and re- cent British authors of repute call croup, is an acute inflammation of the larynx or trachea, or of both, which, when it runs its natural course, generally, they say, terminates in membranous exudation on the inflamed mucous surface. The affection which Bretonneau, Trousseau, Peter, Barthez, Sanni, and the entire modem school of French physicians, call croup, is the membranous manifestation in the larynx and trachea, or in both, of diphtheria, a general asthenic disease, The French physicians, with whom agree Georgs Johnson, Semple, and other British physicians, including the writer, hold that membranous exuf dation is never a result of simple acute inflam- mation, or, in other words, that Uiero is no snch disease as the croup of Home, Cheyne, West, and CEOUP. Sjansom, these authors having blended two essen- tially differeat diseases ia one description, Ho statement could have been vrritt^u intel- ligibly iu respect to the aetiology of ' croup,' with- out these prefatory remarks. The subject now admits of being vei^ briefly disposed of. piph- theritic croup, thnt.is to say, the croup of Freiach authors, lis considered in the article Diputhubia- The common exciting causes of inflammations of the larynx and trachea are exposure to chilly winds and cold damp air; and the sudden tran- sitions from mild to cold wet weather. . Cold weti^^places are those in which inflammations of the laryqx, trachea, bi;onchi, and pulmonary parenchyma are most prevalent. The much greater frequency of these . affections among children in the northern and eastern coasts of Great Britain than in the southern is attributable to the greater rigour of the climate in the former regions. In some localities in northern Europe inflammation of the air-passages is said to prevail at times among children as an epidemic. Perhaps a somewhat exaggerated impression exists as to the greater proportion of cases of inflammation of the Lirynx and trachea, in young chUdren, because in them it generally causes strjdulous breathing. The chink of the glottis, being very small in young children does not admit of being narrowed by turgidity of the mucous membrane without the causation of ^tridulqus breathing to a, greater or ,lss3 .extent. , Even .a slight catarrhal affection of the larynx and. trachea, by exciting spasm, causes stridulous or ' croupy ' breathing in a very young child, whereas .a some- what acute inflammation Eiccompanied by con- siderable swelling of the same parts often runs its course in the adult without producing noisy breathing or aliirm. TsBATMBNT. — The treatment :0f , diphtheritic croup is described in the article. Difhtbeuia. , Injammation of the larynx and. trachi-a, like inflammatory affections of the other parts of the Bir;;passages and lungs, requires to ,b,e treated by antiphlogistic measures. VVhen the inSammar tion is acute, active remedies are called for. Some physicians do not hesitate in such cases to bleed from the jugular yeiji, taking as much as three ounces of blood from a, child two or three years of age. Others, including the writer,, ab- stain from thiS; torpip proqeeding, under the con- viction th^t although it often produce? apparent temporary benefit, it is a benefit always, fraught with evil. The strength, is dangerously reduced ; a fatal.: issue may be precipitated; and when recovery does t»k6 plaice, the course ■ of con- valescence is slow and difficult. It seems safer, and every way better, to subdue the inflamma- tion by blisters and carefully watched doses of ipfcacuan and tarta,r-ometic. If the affection be only moderately sthenic, it is prudent first to use thJo. ipecacuan by. itself: there we many cases, however, in, which the aritiinonial must not, be withheld, Too large a dose of tartar- emetic may give rise to alarming depression. Should' sucli a state ,be induced, the best means of averting danger is watchfully to administer a little brandy, and apply a small blister— say an inch and a half square — over the Sternum about tspo inches belgw. the manubriunj, a warm moist linseed poultice being pUiced over It for three or 21 CROUPOUS, CROUPS. 321 foul hours... Even when no depiession' has been ocCHsioned by drugs, a succession of small blis- ters to the chest is of great use.. Signal benefit is often obtained by a short, and smart purging with calomel and scaramony. In all cases, the legs must be kept enveloped in warm wrappings, moist warmth being preferred if it can be un- flaggingly maintained. In most cases, the breathing is subject to dyspnceal paroxysms arising from spasm of the glottis. The muscular relaxation which follows the emetic action of ipecacuan or tajtar-enietic. generally relieves this spasm with rapidity and for some hours. The vomi- tive effort is also useful in another way — in clearing the air-passages from dangerously accumulating, mucus, and so admitting more air into the lungs. When bronchitis and broncho- pneumonia are associated, as frequently happens, withthe laryngeal and tracheal in-flammation, the treatment is the same as that which has been already descjibed. In protracted cases, ^nd in weak childr,en„.it, is nearly always necessary to give, for a longer or shorter period, brandy or some other alcoholic stimulant. Ammonia too is generally , indicated., The, extent to ,whiph stimulants are demanded varies with each case, and also, with the varying circumstances of each case. . Milk ought to be the principal aliment. Beef-tea, and arrowroot made with milk or with brandy,, may also be given from timo to time. Should .diphtheria be prevalent when we have under treatment cases of common inflammatory sore-throat, we must be specially on the outlook for the supervention of the former. Not in cases of simple, inflammatory sore-tliroat only, but still mors in the sore-throat of scarlatina and measles, diphtheria frequently supervenes as a secondary disease, suddenly declaring itself by an exudation of i false-membrane tin the air-passages. , A new principle of treatment must be adopted when diphtheria engrafts i itself on the original in- flammation. We have then to treat an asthenic general disease as well as the throat-affection. - The possibility of the, supervention of diph- theria, with its accompanying prostration of strength and djyscrasia d the blood, is another argument in addition to those already mentioned against the abstraction of blgpd in the common lary ngo-traoheal ii^^tmmations of young chilr dren; [The article on Diphtheria should be read in connection with this article.] ' JOHli BoSti! COBHACX, CROTTP, FAXiSH. — A term commonly ap- plied to laryngismus stridulus, to^LABiwx, Disea&es of. . , i . , OROUPOtrS, CROTJPY (Scot, croup, to croak). ^-These terms were originally em- ployed with reference to the peculiar crowing or stridulous character of the respiration, cough, and voice in certain affections of the larynx, and signified ' lieloiiging to croup ' in its clini- cal relations ; for example, ' croupy cough,' 'croupous symptoms.' When inorbid anatomy demonstrated the occurrence of a fibrinous exu- dation; pr falsa membrane upon the affected 322 CEOUPOUS, CEOUPY. sniface in a special form of croup, the -word ' croupous ' was used also to designate this false membrane; thus, 'croupous exudation' and ' croupy membranes.' The application of the term was afterwards further extended; and it is now employed to indicate the process that leads to a fibrinous exudation in any situation whatever ; such as ' croupous inflammation,' and ' croupous pneumonia.' Thus the words "crou- pous ' and ' croupy,' which were originally asso- ciated with peculiar bounds, have come in a remarkable manner to express certain physical, chemical, and microscopical characters in the products of inflammation. See Cboxtp, Pifh- TKBEUA, and Inflammation. ono-wima ooirvuiisioiir.— a popular synonym for laryngismus stridulus. See XIabtnx, Diseases of. CBTTBA CBBEBBI, Xiesions of.— From anatomical and physiological considerations we should be prepared to find that a solution of continuity of the crus cerebri would interrupt the sensory and motor tracts for the opposite side of the body. And, further, as the roots of the third nerve pass through the inner aspect of the crus to their nucleus underneath the aque- duct of Sylvius, there' is considerable danger of their being implicated in a lesion of the crus. Hence we should expect, in consequence of such a lesion, a form of alternate paralysis, viz., ooulo-motor paralysis on the side of lesion, and paralysis of voluntary motion and sensation on the opposite side. A typical instance of this form of paralysis has been put on record by Weber {Med. Clin. Tram. 1863). In this case there was oculo-motor paralysis on the side of lesion, and complete paralysis of voluntary motion and partial paralysis of sensation on the opposite side. The partial escape of the sensory tracts is accounted for by the fact that the sensory tracts are situated more to the outer and back part of the crus, and hence tend to escape destruction from a lesion situated in such a position as specially to endanger the cncti- nuity of the third nerve. Vaso-motor paralysis on the hemiplegic side also occurs in a marked degree, and the tem- perature of the paralysed side may be two or three degrees above that of the other. D. Feeeibr. CBTTSTA IiACTSA (erusta, a crust, and lactea, milk-like) ; milk-crust — A synonym for eczema pustulosum of the face and head, met with in infants at the breast. See Eczema. OBTnnBILHIEB'S PAEAIiYSIS. — A synonym for progressive muscular atrophy. See JluscuLAE Ateophy, Progressive. CUPPIIJ-G.— This is a mode of treatment sometimes employed to relieve congestion or in- flammation of internal parts by drawing blood to the surface of the body. When the blood thus attracted to the superficial parts is actually attracted from the body hy means of incisions, the operation is called we<-cupping, and this has been described in the article Biood, Abstraction o£ We shall here describe c&y-oupping, in CUTIS PENDULa. which no scarifications are made, the blood being simply drawn towards the surface hy atmospheric exhaustion, hypersemia of the subcutaneous parts or organs beiiig thereby relieved. Formerly cupping was extensively practised, but of late years it has fallen into disuse. In some respects it serves the purpose of, but has s more powerful eflPect than, counter-irritants; rapid and marked results being sometimes pnv- duced upon the circulation of inflamed or ccu- gested tissues. Modes of Application. — ^Dry cupping is pjt formed as follows:— The flame of a spirit-lamp, being allowed to burn for an instant in the dome of a cupping-glass, is quickly withdrawn, and the cup is then rapidly and evenly applied to the skin over the affected part.' The heat expands the air contained in the glass cupola, and, owing to the contraction which ensues on cooling, the skin is forcibly sucked up into the cup. It is well first to sponge the skin of the selected spot with hot water, so as to render it more supple and vascular ; slightly moistening the rim of the cupping-glass helps to increase the degree of exhaustion. An excellent modification of cupping, which has been demonstrated to the writer by Dr. Quain, is practised iu the following way:— Instead of allowing the cup to remain station- ary after ita application to the skin, as is usual, the operator dexterously slides it to and &o along the surface. When the operation is to be thus performed the amount of surface drawn into the glass must not be considerable. In this way a large tract of skin may be quickly rendered hypersemic without effusion of blood into its meshes, as happens when the cups are stationary, Peecautions. — Cupping-glasses should be applied where the skin is tj^ick and cushiony, aj over the loins, nape of the neck, pectoral region of the chest, &c., and not where bony promi- nences, or other irregularities, are likely to in- terfere with complete exhaustion. The edges of the glasses should not be so hot as to bum the skin. ■ Uses. — Cupping may be advantageously em- ployed in sthenic cases of cerebral congestion, the cups being applied to the nape of the neck; in hyperseini&iof the spinal cord ; and ininflannna- tion or cbngestion of the lungs, kidneys, or other viscera. In renal ischaemia it is eminently ser- viceable. This maybe owing to the fact that the blood supply of the skin of the loins is in intimate : relation with that of the kidneys ; the vascular supply to those organs being thus directly and immediately influenced. Alfeed Wiltshiee. CUTIS, Diseases of. See Skin, Diseases of. CITTIS ANSEBIITA {ouMi, the skin, and anaer, a goose). A state of roughness of the skin, resembling that of a goose when plucked, produced by prominence of the pores or fol- licles. , It is due to contraction of the muscular structure of the corium, and is commonly occa- sioned by cold. CYANIDES, Poisoning Tay.—See Asm- DOTE ; and Pedssio Acid, Poisoning by. ' CYANOSIS. CTAIT0SI8 (nuoKbr, blue).— This -which is really not a disease, refers to the peculiar blue or mora or less liyid colour of the surface of the body, especially in certain parts, which is ob- served Ic several affections that interfere vnth the circulation and oxygenation of the blood. The condition is most commonly associated with, and reaches its highest development in certain forms of congenital malformation of the heart, for which ccnssquently cyanosis is not uncommonly used BS a synonym. Lesser degrees of similar dis- colouration are, however, not infirequently noticed in cases of cardiac disease developed after birth, and they may also accompany pulmonary affec- tions which materially obstruct the ciroiJation ; a cyanotic appearance is also one of the obvious effects resulting from all modes of suffocation, and it is observed in the coUapse-stage of cho- lera. The upper half of the body may become ixtremelycyanotic as the result of obstruction of the superior vena cava. For the pathology of cyanosis, see Heabt, Malformations of. OTWAITOHB (leiav, a dog, and Ayx", I strangle). Synon. : Fr. Angine; Ger. dieSrdune. This word is used to express an inflammatory condition of the throat, or contiguous parts, in which difficulty of breathing or of swallowing exists, accompanied by a sense or feeling of choking. The term is used synonymously, inore frequently on the Continent than in Englaiid, with Angina ; an affix, indicative of the seat or nature of the affection, being employed as a desig- nation for each of the sevenl forms or varieties of disease affecting the throat or adjacent parts. Such, for example, aje the terms Cynanche laryngea, or croup; Cynanche maligiia, or malig- nant sore-throat; Cynanche yOTOr mumps ; Cynanche pharyngea, or inflammation of the pharynx; and Cynanche ionsUktris, or quinsy. See these several diseases. CYRTOMBTER (wuproj, a curve, and iiiTfov, a measure). — An instrument for measuring the absolute and relative dimensions of the chest- wall. . See Physical Examination. CYSTIOEROtrS (Ki'iTis, a bladder, and Ke'pKos, a tail). — ^DBSoniPTioii.-^Cystieercus is a bladderworm furnished with a head which is dis- tinctly visible to the naked eye. The form usually found in man is specificdly identical with the so-called pork-measle, or Cyiticercus (tela) cellulosts. According to Dr. GiacomiLi, however, the human measle commonly displays 32 cepha- lic hooks, whilst the pork- measle carries 21 ; more- over, in the human variety there is a greater adhe- lence of- the measle to its investing capsule. The only other form of cysticercus at Fis. 14.— <^jHcer«« present known to infest the (teteUeBirfojWi removed human hndviatTiB oloniloi.- from the human eye.by numan Doay istne slenaer- Mackenzie, x Sfllame- neoked bladder - worm, or ters. After Allen Thom- Cystitxrctis teimicollis. An son- alleged example is preserved in the anatomical museum attached to King's College, London. This parasite is of £requent'occurrence in the sheep. CYSTIClEECUa. m Situations and Symptoms.— The clinical im- portance of the human measle is chiefly dur Fig. 16. — ^Portion of measled pork, sbowing Oj/stleent. Nat. size. After Lewis. to the circumstance that it is apt to take up its residence in the brain and eye ; those parasites occupying the cerebrum being for the most part situated in the grey or cortical substance. The only serious attempt that has been made to establish diagnostic signs by which brain- oysticerci might be detected d^ing life is that initiated by Griesinger, who based his conclusions on data supplied by the histories of upwards of fifty eases. Symptopis are exceedir^ly variable. In some cases they are altogether wanting ; in a second set, epilepsy exists, without mental dis- turbance ;. in a third set, epilepsy is accompanied with mania or imbecility ; in a fourth siet, mental disturbance may occur without epilepsy; whilst in another group there is neither epilepsy nor mental disturbance, until shortly before death, when syinptomSof irritation or torpor gradually supervene. Since Griesinger ' has himself re- marked that the epileptiform seizures due to cys- ticercus are in all respects like ordinary cerebral epilepsj-, and since also ' the psychical disturb- ances have nothing characteristic about them,' the practical physician is naturally tempted to coueludo that diaghbsis and curative treatment are alike impracticable. The writer, however, ob- jects to that inference, on grounds too Wide for dis- cussion here ; but, as one source of encouragement c?.lls attention to the fact that cysticerci are not very long-lived. He has demonstrated that a period of eight months is amply sufficient for the setting in of calcareous degeneration, a process which involviss the speedy death of the measle. If therefore the presence of cysticerci be so much as suspected in the brain, the prospect of a natui:al cure is by no means hopeless. Hest, both mental and corporal, would of course tend to assist nature's efforts. Cysticerci may develop in aiiy part of the hnman body; their most frequent, situation being the subcutaneous, areolar, and intermus- cular connective tissues. A,mongst the more remarkable cases are five recorded by Helle;r, and one by Greenhalgh, where they occupied the lip ; by Fournier, where several occurred in a boil ; and one by Dttpujtren, where the parasite lodged in the' great peroneus muscle. Mr. R. Davy lately recorded a case in which several were present in ' the arm ; but the well-known mul- tiple cases given by Giacomini, Hodges, Delore, and others, show that hundreds of measles may co-exist in the same human host. In Delore's 824 OYSTICEECTJS. case there were about 2,000, of ■which no less than 84 -were found in the cerebrum! Of in- stances where the cysticercus occupied the eye -we may particularise the cases by Windsor, Logan, Estlin,Kos6, and Mackenzie of Glasgo-w; -whilstof additional brain-cases, those given by J. Harley, Hulke, Burton, Bonvier, Fridault, and Toynbee are particularly noteworthy. Amongst the most recent contributions to our knowledge of, cysticerci are the memoirs of Perroncito (bella panicatura negli animali, in Annali del. S. Accad. d^Agricolt. di Torino, 1872) ; pf Becoulet and Giraud {BuUI de la Soc. Med. de Garid, 1872); of Giacomini (Sul. Cyst, cell, homima e svila, Tania med. &c., 1874), of Lewis {Seport on Bladderworms, &c., 1872), and of Pellizzari, as reported by Dr. Tcmmasi in his Italian edition , of the -writer's manual of , the parasites of our domesticated animals (_Appendice Parasiti, &c. Vermi, 1874). A sum- mary .of, these last-mentioned researches "was giv^n by the 'writer in the Zand. Med. Secord for, 1874 (p. 641). Lastly, it is important to bear in mind that small hydatids, which are also ^able to take up their abode in the brain, may Tevy readily be mistoken for cysticerci, after death; and during life they are apt to give rise to precisely similar symptoms. The -writer has collected records of more than, thirty cases ■where tladderworma occurred in the human ,bi;ajn. , Eeferenees to most of these are given in thfe B^Miography of his Intr9dvcti,bn to the study of Helminthology (ffjiiofija, 1864; and Supplement, 1869). See Bladdek-woems. T. S. COBBOID. , OTSTINE or OTSTIO OXIDE {Kiari^, the bladder)i — ^A peculiar substance occurring either in solution or in the form of small crystals in the urine, or as calculi in the iirinaiy passages. See Ueihb and Calculi. : CYSTITIS (/(liffTis, the bladder). — Inflam- mation of the bladder. See Bladser, Diseases of. CYSTS. — Definition.— The ■word cyBf((ciiirTis, the urinary bladder) is used in pathology for a closed cavity containing fliiid or softmatter. The nature of the ■yrall is unimportant ; it may be newly formed or a pre-existent structurei The objects thus defined differ much among them- selves, and are associated together rather from convenience than op account of any real patho- logical similarity. ' , GLAssiriCATiow. — Cysts may be classified ac- cording to thei? strueture, as simple or oom- poimd ; according to their contents, as serous, mucous, fatty, etc.; ot according to their mode of origin. Tlfe latter, though notfree from objec- tion, is the basis of description which will be here adopted,,, Cysts may originate (1) from dilatalion ; of pre;vions,ly existing closed . cavities ; (2) from reientimi o^ products of pecretion ; (3) from exudation, or the metamorphosis of exuded products; (4) as a part of new-^rowtt ; , (5) by a vice, of development ; and, finely, (6) from the growth of ^orasa^es. 1. Cysts from Dilatation.— Spaces, normal or newly formed, in connective tissue may, by irri- tation and consequent excessive exudation, be con- verted into cysts ; or the same result may happen CYSTS. from the confluence of sever&l suph space?. lu proportion as the wall becomes smootli, and the shape uniform, they may becalled cysts. Burse, whether normal or pathological, are cysts. Ganglion in the sheath of tendon is clearly a pathological cyst. ' To these and likja structures the name Hygrtima has been given. They all contain clear serous fluid, and are liiied by an endotlielium. Hydrocele, or dilatation of th« tunica vaginalis testis — an affection probably always due to a low form of inflammation— is another instance. One class of ovarian cystu comes under this head, those, namely, wliich are due to siiiiple dropsy of the Graafian vesicle. Tubo-crarian dropsy has the same explanation ; and cysts of the broad ligament are enlargements of normal structures which are left as relics of the developmentof the ovary. The thyroid gland seems from its structure, containing, as it does, so many closed follicles, particularly disposed to this kiiid of cyst-formati.on, and this is doubtless the explanation of bronchocele. 2. Cysts from Betention. — Cystic formatione may result from the obstruction of the natural outlet of a secreting orgap, and the consequent retention qf.secretion. It, is necessary that ths walls of the secreting, cavity should admit of enlargement, and tha,t the , tension, should not become so great as to check secretion. , ,A11 secreting glands present instances of saeh cysts. iThe sebaceous glands of the skin are paf- tioularly liable to obsti^ction pf their duct^ and in this ■way are formed sel)aceous cysts, miliaiia, and comedones ; the contents of which are some- times epithelium and the products of nornjal secretion, sometimes abnqrmal products, such aj pus. &C Eolliculas Diseases. ITie glands or inucous surfaces are, liable to similar obstructions, and mucous cysts result, pueh as are sometimes seen , in the mouth, .Larger cysts in the mouth (^amda) result from the obstruction of the ducts of the salivary glands, or are perhaps connected with an abnormal pro- duction of gland-substance. The stomach , very frequently, other parts of the intestinal canal more rarely, show similar cysts, which, ■when they project and become complicated in structure, are called polypi. They are occasionallf seen on the larynx and trachea. In no part are mueous cysts more frequent than in tjhe uterus, where indeed, similar formations,, the omila Naiothi, must be regarded as normal. The varieties here met -with have, as Virchow has pointed out, a close analogy with the variou.'i forms, of retention- cysts in the skin. In the mamma, cysts may result from the cut- ting off of portions of the gland-follicles, but the cysts contained in mammary tumours are not always formed in this way.some being part of new growths. In the testiclepbsti;uction;and,catling off of seminiferous tubes may lead to small cysts, but these are more oiFten connected with new- growths. The curious cysts known as sperma- tocele, containing sperrnatozoa, appear to arise from a similar di6tensio^ of detached portions of testicle-substance, whiph, by an error of deveJpp- ment, have failed to become connected with the excretory ducts, The testicle is also liable to a general cystic degeneratipn, usually called ejfsto- sarcoma. Qysts of the kidney are of TarioM kinds, tut many, no doutt, toth la!rge and small, result from the dilaution of'uriniferous tubules and capsules of glomeruli wlien their outlet is obstructed, as oCi"urs in the cirrhotic form of Bright's disease. The origin of the very nume- rous microscOijio cysts has been much disputed. The writer inclines to the belief that they arise from moniliform contraction of the uriniferous tubes, eapecially such as contain the hyaline cylinders, Known as fibrinous casts. Another form of cystic disease of the kidney is developmental. In this the -whole of the organ is converted into' a mass of cysts, and is usually much enlarged. This condition may be congenital, and the organ may be so large as to obstruct parturition. ' It is attributed by Virchow to inflammation of the calyces during ittra-uterine life. To guard against a common error of language, it should be pointed out that the condition of the kidney which results from the obstruction of the ureter, or of the urinary passages lower down,, though sometimes called cystic dilatation of the kidney, is not properly a case of cyst-formation, End is better cfdled hydronephrosis. 3. Cysts from Exudation. — Ejruded ma- terials, such as blood and inflammatory products,^ may, by a process of degeneration, central' softening, and external fibrous formation, become converted into imperfect eysts, as is seen in the, metanicrphosis of a blood-clot in the brain, and in the termination of some abscesses. But since the accumulation of fluid does not go oA/Con- tihually, the tension in such cavities is sliglit, and they do not approximate to a globular 4. Cysts from New-Growth. — In many forms. of new-growth cysts are produced, but not always in the same way. Sometimes, as in myxoma and enchondroma, they result from sottening of portions of newgrowtli already formed^ In many sarcomata, the production of new tissiie goes hand in hand with that of cysts, and is sometimes effected as in glaiidular organs, by the formation of new follicular structures without an outlet, sometimes by new-growth into the dilated cavities. Po;lypoid or pedun- culated growths on a free surface 'may some- times, by the fusion of their extremities, en- close'spaces which become converted into cysts. We do not, however, find cysts forming by them- selves a new-growth of so definite a character as to deserve a separate name. 6. Developmental Cysts. — These include (n) compound ovarian cysts ; (A) dermoid cysts. Cysts are met with in the oyary which come under none of the definitions just given, viz., the so- called compouK(2 muZ^iVocu/ar cysts, which, cou: stitiite the well-known formidable cystio diseise of the ovary, and sometimes produce tumours of immense size. In these the originally simple primary cyst appears to become complicated by the formation in its walls of secondary cysts, which may encroach upon or project into the primary. Agaiii there may be papillary growths starting from the inner wall of the primary cyst, which either fill it up, or by fusion enclose spaces, which become secondary cysts. Very com-, plicated structures thus result. The contents maj- vary in consistence and colour, from clear, pale, albuminous liquid to gelatinous matter, and CYSTS. ' 326 may be stained througli hsemorrhage, or purulent through inflammation. Tlie origin of theis'e etrv)C- tures, which have no precise plirallel in other parts of the body, is extremely obscure. It is not, even certain whether the priniary cysts commence, as might seem prima faine highly probable, in the Graafian follicles ; but they are plainly due to an error of development, pcssiblj beginning in early intra-uterine life, and are not set; up by any external causes. The presence oif a tubular gland-tissue, siich as is found in the judimentary, but not in the perfect ovary, confirms this view, by throwing cyst-foi-mation bSiek into' an early stage in the development of the organ. In another, but rarer form of, cystic disease of the ovary, equally due to an error of develop- ment, and sometimes congenital, the whole organ is found converted into a mass of small cysts, with no striking inequality of size. This variety resembles one form of cystic disease in the testicle and kidney. Dermoid cysts are those containing seba- ceous matter, and which are lined by a layer of fiat cells resembling epidermis. The wall may be complicated with connective tissue, forming papillas resembling those of true skin, and may contain hairs, sebaceous glands, either in con- nection with them or unattached, and sudori- parous glands. The accumulation of fatty matter within the eysts is 4oul'tiess the r,esult of the. continuous activity of the setaceous glands, the produpts of , wjiich cannot escape. Large masses of hair may also be found, froni coiir tiuuous growth, and there are often numerous detached JepideiMrfic scales. Such a cyst has only the characters of a portion of -skin, -which might' be imagined invested and included by the growth of the surrounding parts in an early stage of development — an explanation formerly entertained. These simple dermoid cysts are sometiines complicated by containing teeth, it may be in very large numbers {dentigerous cysts), but since teeth may also be regarded as cutaneous products! the cyst , may still have originated in the skin. This explanation no longer Jtiolds, however, w;hen massps ,ot bone, are found, sometimes serving for the attachment of teeth, sometimes separate ; as weil as other tissues, e.g. nervous (issue and striated' muscle. Cysts with this variety of contents have been called ptoli- feraiive. Dermoid, dentigerous, and proliferative cysts appear to be always, congenital structures, but may show further growth and development in after-life. At least- two-thirds Of the known cases have occurred in the ovaries. Next to these organs, the testicles are the most frequent seat, but these cysts have been also.foiind' in other parts of the body-cavity, in the medias- tinum, lung, and even within the skulij The origin pfthepe growt,h,S'is extremely obscure; but it is desirable to i:eject entirely, the hypothesis that a mixed tumour of this kind can be the remains of an undeveloped foetus included in the perfect individual ; n, hypothesis, rendered improbable by the extreme irregularity of the ! tissues produced, the teeth, for instance, some- times numberirg one hundred or more. It would rather appear as if a portion of embryonic ' tissue, from the upper and middle germinal 326 CYSTS. layers, became misplaced at an early period of development. . . 6. Parasitic Cysts.— Several parasitic ani- mals infesting the human tody may appear in an encysted form, and may resemble in appearance true pathological cysts. The commonest, the larval form of Tcenia eehhtococcus, or hydatid cpst, is kno-wn by its laminated vcall, and by containing , a fluid which is not albuminous, but holds in solution sodium chloride. Cysticercus cellidostB has a transparent wall and clear contents. The other encysted parasites are either very small, as Trichina spiralis, or unim- portant. CoKTENTS OF CtsTS. — The serous cysts and hygrcmata contain an albuminous fluid like that of serous cavities, which may hold enough fibri- DEATH, MODES 01?. nogenous material to coagulate ejjontanTOUsly Leucocytes may also be present. If inflammation be set up. the proportion of albumin and of leuco- cytes becomes greatly increased. In the fluid of mucous cysts mucin is contained; in that of colloid cysts, little-known substances which aw allied to gelatin. Sebaceous cysts contain neutral fats — sometimes hard, sometimes fluid, and oholesterin. Both mucous and sebaceous products may harden into concretions, and even become calcareous. In renal cysts urea has been fonnd; ill biliary cysts, bile-pigment; and in general the products of special secretion may be found in cases of retention, at least in early stages, but if retention last too long, special secretion may cease. Various exceptional contents have been already enumerated. J. F. Patkb. D DACTYLITIS {iiKTu\as, a finger). — ^A term meaning inflammation of the finger. It is ap- plied to syphilis and struma of that organ, as in the terms dactylitis syphilitica, and dactylitis strumosa. D AKD BIFI", or DandrufT (from two Saxon wordssignifyingiicAfoess KadLfoutwess). — Synon. : Furfur; Scurf of the Head.— Dandriff is met with in pityriasis, chronic eczema, and lepra vulgaris or psoriasis of the scalp. D AWD Y FE VEB. — A synonym for Dengue. See Dengue. DABTKB (Ft.). — This term is the French equivalent of the word tetter, and is applied to a variety of cutaneous diseases, without strict limi- tation. DAVOS, in Worth Engadine, Switzerland. A dry, cold, bracing, winter-climate. Altitude, 5,177 feet. Season, October to March. Winds, N.E. and S. See CtiMATB, Treatment of Dis- ease by. DAT-BLINDITBSS. — A disorder of vision, characterised by the patient being unable to see during the day: also called Nyctalopia. See Vision, Disorders of. DEAPITB33. — Loss of the sense of hearing. See Eab, Diseases of. and HuABiNa, Disorders of. DEATH, Modes of. — The proximate causes of death, whether resulting from natural decay, disease, or violence, may be reduced in ultimate analysis to two, namely, first, cessation of the cir- culation ; and, second, - cessation of respiration. On the continuance of these functions, and par- ticularly of the former (if specialisation is pos- sible where all are essential) life of the body as a whole, or of the indiridual tissues and organs, depends. These functions may cease from causes directly operating on their meehanisni, but they may also be brought to a standstill by causes operating indirectly through the nerve-centres which regulate them. Hence it is usual, in accordance with Biehat's classiflcation, to de- scribe this as a third mode of death; so that we speak of death beginning at the heart,, death beginning at the lungs, and death beginning at the head. This classification is convenient ; for though death beginning at the head is, in reality, death from failure of the respiration or circula- tion, or of both, through paralysis of the vital nerve-centres, yet the affection of the nervous system is the primary fact, and the phenomena are suificiently distinct and characteristic to require separate consideration. It must, how- ever, always be borne in mind that, owing to the interdependence of all the vital functions, there is no such sharp line of demarcation, in reality, as we, for convenience' sake, make in theory be- tween the various modes of death. I. Deatli from failure of the Circulation. — This may be (1) sudden, as in syncope mi shock ; or (2) gradual, as in asthmia. (1) Sudden failure of the Ciretdation. — As the circulation of the blood depends on . the difler- ence in the pressure in the arteries and vnne, the circulation will be brought to a stiindstijl by any cause which annihilates, or very greatly lowers, this differential pressure. The cause may be in the heart, or in the vessels, or in both. (a) In the heart. As the action of the heart is the chief factor in the maintenance of arte- rial tension, any organic or structural disease of the heart, rendering it incapable of propelling its contents into the arterial system, will natu- rally result in cessation of the circulation, and death. Under this general head . are to bo classed all diseases of the heart and its annexes. But apart froff structural disease, the heirt may suddenly be made to cease through nervoju DEATH, HODES OF. influence. The heart may be inhibited, or be made to cease finally and for ever either by central causes, such as violent emotion, or a blow on the head ; or by reflex inhibition, as in the case of a violent blow on the epigastrium, or sudden irritation of the sensory nerves of the stomach, as in corrosive poisoning, and even in the ingestion of a large draught of cold water when the system is overheated. Death from sudden cessation of the heart's action is death from syncope. Momentary ces- sation of the heart's action is transient syncope or fainting. There is sudden loss of conscious- ness, due mainly to the cessation, of pressure in, and ansemia of tlie cerebral centres. (i) In the vessels. Eapid fall of the blood- pressure, and cessation of the circulation, will naturally be brought about by rupture of the vessels, either from injury or disease, causing death by heemorrhage. But besides actual rupture of the vessels, the vascular area may in certain conditions become so en- larged or dilated that we may practically have death from haemorrhage without any loss of blood externally. This is what wo observe in death from shock or collapse. In certain condi- tions, such as that resulting &om blows on the abdomen, the vascular area of the abdomen and viscera may become so dilated as practically to retain almost the entire volume of blood in the body. Hence, even though the heart may be acting, yet the circulation throughout the body generally, and especially in the extremities and superficially, is practically nil, ■ The ■ individual may, however, retain his con- sciousness, and thus he differs from a patient in a state of syncope. But very frequently in cases of blows on the abdomen, there is not merely reflex dilatation of the abdominal vessels, but also reflex inhibition, for a time at least, of the 'heart, so that we have syncope and shock co-existing. But the symptoms of syncope may pass off, leaving those of shock still remaining. Shock, like syncope, may be transient or fatal, (2) Gradual failme of the CireulaiUm. — ^^ ThiS' constitutes death from asthenia. This is the natural termination of life, and it is also the mode of death after wasting and exhausting diseases, cold, starvation, &o. The vital powers fade gradually, while consciousness may be re- tained up to the last moment. II. Death &om failure of tlie Kespiration. — The various ways in which the function of respiration mny be interrupted, and the pheno- mena consequent thereon, have been described under the head of Asphyxia, to which article reference may be made. III. Death from paralysis of the vital nerve-centres — Coma, — As already remarked, death beginning at the head ends by paralysing respiration and circulation. The nerve-centri s situated above the medulla and pons are not essential to life except in so far as animal life is concerned, and the possibility of adaptation to surroundings. Diseases of the brain, however, are liable to prove fatal by indirect action on the medulla and pons through pressure, exten- sion of inflammation, and the like. Certain poisons also, whether introduced from without. — such as opium and narcotics generally, — or DEATH, SIGNS OF. 327 arising within, owing to the non-elimination of waste products, as ia ursemia, affect the nerve- centres, both cerebral and spinal, and not only produce unconsciousness or coma, but also paralyse the respiratory and cardiac centres. In death arising in this manneir, the indivi- dual lies unconscious, reflex action becomes abolished, and the breathing becomes stertorous and ultimately ceases, death occurring quietly or in convulsions. In death from coma, in addition to the usual phenomena of asphyxia, there is, as a rule, more or less marked congestion of the cere- bral and spinal centres. D. Fbekieb. DSATH, Signs of. — It is not always easy to determine wjien the, spark of life has become finally extinguished. From the fear of being buried alive, which prevails more abroad than in this country, some infallible criterion of death, capable of being applied by unskilled persons, has been considered a desideratum, and valuable priEes have been offered for such a discovery. The conditions most resembling actual death are syncope, asphyxia, and trance, particularly the last. We cannot, however, say that any infallible criterion applicable by the vulgar has been discovered, and we do not rely exclusively on any one sign, but combine several. The most reliable sign of death is proof of cessation of the heart's aetion. This, however, is not to be inferred from mere pulselessness, for the heart may still be beating, and resuscitation may be possible, when no pulse is to be felt in the arteries by ordinary manipulation. The use of the stethoscope is necessary, implying, of course, technical skill.' Though, according to Rayer, the heart cannot cease to beat for more than seven seconds without death, y^t, consider- ing the very slow and feeble action of the heart (8 to 1 beats per minute) in hybernating Animals, which normally have a pulse of 80 to 90 per minute, it is well to regard a similar conditior as possible in man, and to spend in doubtful cases some minutes, up to half an hour, ir auscultation. The so-called cases of life con- tinuing notwithstanding cessation of the circu- lation, as that of Colonel Townsend, or of the Indian Fakirs, are to be set down as altogether apocryphal, and not scientifically investigated. To enable unskilled persons to determine whether the circulation continues or not, Magnus recommends the application of a tight ligature on a finger or toe. If the circulation has quite ceased, no change in colour is produced ; but if circulation continues, however feebly, the ex- tremity, in coui^se of a longer or shorter period, assumes a livid tint from strangulation of the venous Bow, yhile a ring of arterial anaemia is observable at the point ligatured. Cessation of the heart's actioii, if absolutely established, renders other .indications unneces- sary. As aocfssories they are useful, but the following signs are none of them individually conclusive taken alone. The first is cessation of respiration. Respiration may not be very obvious, and yet it may be going on. The popu- lar methods of holding a cold' mirror before the mouth and nostrils, and looking for indications of moisture; placing a flock of cottonwool on the lips to ascertain whether air-currents exist ; 828 DEATH, and placing a cup of water on the chest, and observing whether the reflection on its surface moves or remains stiU, are all well adapted for the purpose in view. , With the Cessation of the circulation and vital turgor, the skin becomes ashy pale, and the tissues lose their elasticity. The eyeball becomes less tense, and the cornea becomes opaque. The pupils cease to react to light; and there is no vital reaction on the application of irritants to the skin. Though the body is dead as a whole, certain parts may continue to retain their in- dependent vitality after somatic death. This is seen in the muscles, which may retain their electrical contractility from two to three hours after death. The existence of electrical con- tractility of the muscles in a body supposed to be dead indicates life, or death within two or three hours, accorfing to M. Rosenthal. The subsequent changes which occur in the dead body not only indicate the fact of death, but aid in fixing the probable period at which death occurred. These are the following : — (1) The coQling of the bodi/.-^The body after death, except under certain special circumstances, as in fatal cases of cholera and yellow fever, ceases to be a source of h^at-production, and therefore is to be looked upon as an inert mass possessed of a higher temperature than the average medium, which parts with its heat ac- cording to certain physical laws. The superficial coldness of collapse, which is due to cessation of the peripheral circulation, must not be mistaken for the cadaveric coldness, for there is still an amount of internal heat which has to be parted with, and the body, cold to the touch Before death, may (ifter death rise in temperature, as the internal heat radiates. It is impossible to describe here in detail all the circumstances which modify the rate of cooling of the body, but it may be said in general that all circumstances which favour Radiation, convection, and con- duction of heat in inorganic bodies are equally applicable here, while the opposite conditions retard. Therefore a thick coating of adipose tissue, clothing, &c., .retard cooling. The exact thermometric observations bf Brs. Wilks and Taylor show that at an average temperature, and without clothing, a dead body cools at the rate of about 1° Fahr. per hour. (2) Hypostade. — ^After death the blood gravi- tates to the most dependent parts, both ex- ternally and internally, giving TJse to livid dis- colourations, termed hypostases. These are liable to be confounded with ecchymoses or extrava- sations externally, and with the results of con- gestion and inflammation in the internal viscera. They differ from ecchymoses in the fact that the blood is not. extravasated into the tissues, but still contained in the vessels, as may be shown by an incision into the' skin. So' long as the blood remains fluid, these discolouratioiis may be caused to disappear if the position of the body be reversed ; they will again form in the parts which are now the most dependent. They usually occur in from eight to ten hours after death. (3) Eigor mortis.— After death the muscles become stiff, giving rise to ri^or mortis or cadaveric rigidity. It is due to coagulation o^ SIGNS OF. the ■'miisdc-plasjnli.' This rigidity attacks the muscles usually in a certain definite order, be- ginning in the muscles' of the neck and fee, and gradually extending fromabove downward*. It gives way to putrefaction in the same order, so that while the uppoi' parts of the body may. be flaccid, the legs may be' found rigid. It can only be overcome by tearing the tissues, and if overcome it does not return. In this it differs from cataleptic rigidity. A certain amount of mobility is still observable at the joints. In this it is unlike the stiffness of freezing, in which all the purls are equally rigid, and crackle if bent. The period ' of the occurrenfce of rigidity, and the length of its endurance, are extremely variable, ' so that no definite practical rules can be laid down; It may be said generally, however, that the greater the store of mus- cular energy at the time of death, the longer it is before rigidity sets in, and the longer it lasts. On the contrary, the greater the ex- haustion, the sooner rigidity sets in, and the sooner it disappears. Hence rigidity is longer in ap- pearing in subjects dying; suddenly in flill mu»- cular vigour, than in those dying from exhaus- tion. As a rule, a period of relaxation intervenes between death and the occurrence of rigidity; but in certain cases the last muscular contraction seems to pass directly into the rigidity of death. This is seen more particularly in death during great nervous excitement, as in soldiers in the field of battle, or in suitides. The sameis said to occur also in death from strychnia-poisoning and in death by lightning. Rigidity may therefore occur immediately on death or within a few hours. It has never been observed to be delayed beyond a day after death: It ma}' last from so short a time as scarcely to be perceptible, up to a week or more. (4) Putrcfdetion. — After death the tissues nn- dergochanges in colour, consistence, &c;, by which they are ultimately resolved into their simple elements, included under the general term putre- faction. Putrefaction, however, may occur locally during life, and general septic changes may occur to some extent before death. The term, however, is not • generally applied' until the changes are clearly perceptible in alteration of colour, consistence, and smell. The first external sign is a greenish discolouration of the abdomen. Internally the mucous membrane of the larynx and trachea is the first to exhibit change in colour and consistence. The less compact tissues putrefy first, the fibrous tissues resist longer, and the compact tissue of the uterus resists longest Of all. In process of time, however;' the soft tissues become entirely disintegrated and the skeleton is exposed and'gradually falls to pieces. The rate Of putrefaction is very variable, de- pending partly on the' state of the body itself; but mainly on external conditions as to tempera- ture, moisture, and exposure. A combinntion of high temperature, moistiire, and free expo8ure,are the most favourable conditions for rapid putrefac- tion. A high temperature alone without moistuie tetids to dry the tissues, and thus to produce mum- mification, instead of coUlquative' putrefactiodi Moisture aloiie, as when a body lies in water of moist earth, tends to produce a saponification of the tissues, more particularly the Mty, \nth the DEATH, SIGNS OF. formation of a substance termed adipoeere (see Adifocebb). The course of putrefaction can be Btopped by antiseptic?, %a in'embalming, and in certain cases of poisSning, as with arsenic, as also by freezing. Putivfaction is more rapid itf air than in watsr, and least rapid in earth. Under ordinary circumstances and average temperatures, Signs of putrefaction are clearly visible on the third day after death, commencing with the green hue of the abdomen. ' Many months elaftse before the soft tissues become entirely disintegrated. ' The uterus has been fbtind fit for judicial examination as long as nine months after death, where no antiseptics had been employed. When such has been the case, however, there is practically no limit to the period of preservation — witness the-Egyptian mummies. There is. still much to be learnt respecting putrefaction, and it is unsafe to lay down dog- matic rules as to how fer putrefactive changes shall have advanced at a given time, for even under apparently similar conditions the most extraordiriary (Kvergences have' been recorded. D. Feueibe. DBBIIiITT (rfeWfe, feeble). Stnon-. : Feeble- ness; Weakness; Asthenia; ii. Faiblesse ; Ger. Schwiiihe. Definition.^ — The body or any of its organs are said to be in a state of debility when their vital functions are discharged with less than th^ normal vigour, being reduced in the amount of activity that they display, and of work that they can accomplish. The term debility is also em- ployed in a somewhat different sense in the case of constitutional weakness of an organ, to'convey the notion of vulnerability or predisposition to disease. In this acceptation, ' pulmohary de- bility,' for example, signifies a peculiarly delicate ' build ' of the lungs, which renders them more than ordinarily liable to succumb to the'causes of disease. .SItioloot. — Debility is frequently constitu- tiqnal and inherited ; but it is more often de- veloped after birth. It is most commonly due to impaired nutrition, whether this be prolonged and moderate, as in defective hygieUe or chronic illness, or, on the other hand, rapid and extreme, as in acute disease. Another frequeht cause of debility is abuse of the aftected organ. Over- use of any part leads to fatigue, ' and if fi-equently repeated to exhaustion, the chief feature df which is extreme debility, as in eases of sustained mental eiertion or of repeated strain of the heart. On the contrafy, an organ may become feeble from want of ' eiei^cise. Paralysed muscles furnish the best examples of this condition, biit the same may be seen in all organs after unnatural rest. SyjtPTOMS. — The natui^al ability of the oi^ gans to perform their functions varies extremely with sex, age, previous exercise, and many other oircumstancesi Debility, or the loss of this fiinotional power, is therefore frequently ill-defined; and, when unquestionably present, may vary greatly in different easia, from a con- dition in which fatigue comone cause, viz., increase in the size of the lungs. Increase in the size of the lungs generaDy, and pretty uniformly, is the consequence of disease, and of one disease only, viz.. large-lunged or hy- pertrophous emphysema. When the increase in size of the thorax attending large-lunged or hy- pertrophpas emphysema is moderate in degree; the increase in its size is effected by the altered position of the ribs ; but when the lung-disease IS extreme, then a certain amount of the enlarge- ment is caused by pressure on the inside of the chest during the violent expiratory efforts of severe cough. 3. Irregular General Deformities. — In the de- DEFOEMITIES OF THE CHEST. 381 formities above deaoribed the antero-posterior and the lateral diameters retain more or less per- fectly their normal proportion—both are in- creased or both are diminished; in the former case the chest is on the whole more barrel-shayped than natural, but the deviation from the normal furm is not considerable. If, however, the chest- walls are from any cause unduly soft or unduly rigid, then the actually or relatively soft portions will recede during each inspiratory act, aul local defbrmity of the chest follows. The diameter of the chest at the part where the absolutely or relatively soft portion of the parietes is placed will be diminished. The special deformities of the chest which result are due, therefore, prima- rily to the state of the parietes, and are not, as those previously described, secondaiy to con- ditions of the lungs themselves. a. Biminuiion in the antero-posterior diameter of the thorax. — The antero-posterior diameter of the thorax is frequently loss than that of the normal thorax, the lateral diameter being pro- portionately increased. The chest has an oval form — it is flattened from before backwards. The thorax flattened from before backwards is usually associated with small lungs, but the mechanical cause of the flattened form is the want of fuU. resisting power in the ribs and considerable strength in the cartilages. These conditions of thorax are common in the subjects of tuberculosis. The flattening of the thorax is increased by all impediments to the free passage of air through the air-tubes. In some children suffering from even slight bronchial catarrh, the flattening of the chest is seen to be increased at each inspira- tion ; and if the impediment to the entrance of the air to the pulmonary tissue be constant or extreme, not only is the flattening increased at each inspiration, but the sternum is also depressed, especially at its lower half below the level of the costal cartilages, and thus the antero-posterior diameter of the thorax is still further diminished in the median line. A. Increase iip the antero-posterior diameter of the thorax. — In rickets the cartilages of the ribs are very firm, whilstthe ribs themselves are softer than natural, and especially so near to their enlartced growing ends — the softest part of the ribs ; that is to say, just outside the nodule formed at the spot where cartilage is in the process of growing into bone. The consequence of the extreme softness of the ribs at this part is that at each inspiration the weight of the atmoi-phere presses inward the softest part of the ribs, while the sternum is borne forward by the firm cartilages. The result is great increase in the antero-posterior diameter of the thorax, and diminution of the lateral diameter at the part corresponding to the softest part of the ribs. The depression of the softest part of each rib is increased by the want of resilieuce of the softened structures. A groove is thus formed in the thoracic walls just posterior to the rickety nudules ; and this groove bejng deepened at each inspiration, the part of the lung adjacent is compressed in place of being expanded during the inspiratory act. At the same time, in consequence of the 1 cartilages and sternum being tlurust forward at 382 DEFOBMITIES OF THE CHEST. .each inspiration, air enters witli Tindne force into the lung-tissue subjacent to these parts. The consequence of the excessive expansion of the antei:ior part of the lung is vesicular emphy-' sema, and the recession duringinspiration of the softened and imperfectly resilient and therefore deeply grooved part of th8 chest- wall leads to col- lapse of the silbjaoent pulmonary tissue ; and, as the effect of these two conditions, the lungs, when the chest is opened, present a vertical groove corresponding to the groove in the chest-walls. The anterd-posterior diameter bf the thorax in rickets is still further increased bj thecurvation of the spine. Tne muscles are weak, the child is unable to sit Upright, that is to say it is unable, in' consequence of the weakness of its muscles, to support the weight of the upper paTb of its body, the bones of the spine are, 'in common with the other boties of the body, softened, and the result of the weakness Of the muscles and the' sbftness ■ of ' the vertebrae is the dorsal boTV. When deformity of tlie chest is the result of undue softness Of the chest-walls, the position of the solid orgafls subjacent to the parietes is fre- quently percftplible to the eye. The liver supports the lower ri bs on the right side,'the heart supports the ribs and cartilages over it on the left side, and thus these organs cnuse local prominence of the chest'Witlls withbut beiiig themselves inAny w'ay abnormal. In the so-called pigeonrbredst, the antero- posterior diameter of the thorax' is increased in the middle line, the lungs are small, the ribs and cartilages are firni, the ribs are placed obliquely and the' chest-wklls are' flattened later- ally, ind the sternum as a consequence is thrust forwards ; thus the chest in the pigeon-breasted has a triangular form, the apex of the triingle being the sternum. Impediment to the free entrance of air intb'the lower lobes of the lungs will favour the productidn of and increase the de- formity. The chests of children who suffer from repeated attacks of bronchitis, but are otherwise healthy, are commonly the subjects of this de- formity, while there is increased expansion and subsequent ienlargement of the upper part of the chest, the lungs being more or less collapsed below and emphysematous above. c. Transverse anterior ctmstricfion of the lower part of the thorax is the consequence of small siise of the lung, or of imperfect inspiratory ex- pansion, permanent or frequently recurring in yduth. In these catees the lower' ribs are little used in respiration, while below they are borne out^^■ardst■r supported by the livei:; stomach, and spleen, and thus an imperfectly fontted' trans- verse depression is produced in the front of the chest on a level with the base of the ensiform cartilage. The deviations from the type' of the normal thorax hitherto described are bilateral, and more or less symmetrical! II. — Local, unsymmetrical, and unilateral deformities.^l. Fulness of the mpraclavioular regioti. — The supraclavicular region, correspond- ing tn the portion of the thoracic cavity above the clavicle, may be fuller than natural The causes of tliis local bulging- are— a. Develop, ment of adipose and cellular tissue, b. Disr tension of the deep-seated veins, e. Large-luiuj emphysema, in which disease there is occa- sionally distension of that part of the cavity of the thorax which lies above the level 'of the clavicle; the distension is due to pressure on the inside of this puit of the thoraeic cavity; air being' foiced violently into this part of the lung during tho powerful expiratory effort of cough. ' ' 2, Depression of 6ne tupracldvlcular' fossa is caused hy any pathological condition of the apei of the lung which produces diminution of its' ■ bulk, e.g. atrcphous emphysema, or chronic con- solidMion of the apei 3.' Elevation of one «to(/ife>-.— Occupation is a common cause of elevation of one shoulder ; thus in clerks, who sit much at the desk,, the left shoulder is permanently a little higher thaii the right; and the upper portion of the spine is slightly curved, the convexity being to the left; so in those who carry heavy ■weights on one arm, the opposite shoulder is elevated and the' spine curved. 'Whatever necessitates an increase in the capacity of one side of the thorax causes elevation of the shoulder on the same side : thus, ■ considerable dilatation of the heart, fluid 'in tlie pfericardium, fluid in the pleura, aneurism of the arch of the aorta or of the innominate, all lead to elevation of the shoulder. The shoulder is depressed and carried forward when, from any cause, the whole or upper part of one' side of the chest ' is diminished in size, e.g. when the apex of the lung is the seat of chronic pneumonia dr chronic phthisis. 4. Vnform dilatation of ori-e'sideot the thorax : is due, with one exceptii m, to fluid or air in the pleura; the exception is those rare cases of encephaloid cancer of the lung, in which the formation of cancer is uniformly diffused through the" luiig-tissue, and in amount so great that the ;lung ' infiltrated' with cancer very decidedly ex- ' oeedis in bulk the healthy lung inflated with air by inspiration. In uniform dilatation of one side of the thorax, the shoulder is raised, the ribs are placed more horizontally than on the healthy side, the inte^ costal spaces are widened, and the spine slightly curved. "When the enlargement is inoderate in amount, the increase in capacity is effected by the altered position of the ribs' ; but when the increase in size is very considerable, then it is due in part to the pressure exercised by the air, fluidi or cancer-loaded lung on the inner side of the chest-wall. 5. Uniform contraction of one side of the the rax is the consequence of any pathologieiil' con- dition which leads' to general and uniform redui- tion in the size of the lung, e.g. cirrhosis' of the lung, infiltrated cancerof the lung, chronictuber- cular disease of the lung, chronic pneumonia, or the change in the texture of the lung whioli follows long-continued compression by fluid ill the pleura. When the whole of one side of the thorax is reduced in size, the shoulder on that side is depressed, the ribs are placed more obliquely And are more closely ap{)rA2imited than on the opposite side, the intercostal spaces are narrowed, and the spine is curved, often consider- ably, the concavity of the curve being towards the contracted side. DEFORMITIES OF THE CHEST. 6. Lateral eurva^pre qf the spim, instead, of being the consequence, may be tbe cause of defor- mity of, tjia tborax : lie ribs are then approxi- mated on the side and at the part where the concavity of the curvature is placed, -yvhlle thay are , separated and the shoulder raised on the aide of the convexity. , _ . , . 7. In g,ngular cunatvro of the sf%ne the defor- mity of the thorax varies with the seat and the extent of the vertebral disease ; but, spealiing generally, it may be said that in angular curva- ture of the spine the antero-posterior diameter of the thorax is increased in , proportion to the, amount of destruction of the bodies of the ver- tebrae, and that the ribs are in a corresponding degree ipproximated.. 8. Extreme depression of the lower part of the sternum is the oonsequentee of softness of the '. cartilages of the riba and impediment to thd free passage of the air to the pulmonary tissue. This deformity is never congenital, although the Subjects of it often affirm it to be eo ; it may, however, commence to be formed directly after birth if there be a congenital mipediment to the entrance of air iQto the lungs, e.g. atelec- tasis. The deformity may be the result of direct pressure. In certain occupations pressure has to be exerted on the lower part of the ster- num — ^thus, some shoemakers use a wooden in- strument which has to be kept in its place by pressure. against the lower part of the sternum. Jor direct pressure to produoe this deformity it must haveTiBBi>«ppUed ia early youth, while the parts are still flexible,; and have been exerted frequently over a Ipng period of time. ,' ,9. Congenital deformities ,of , the thorax are few In ,number and are due to arrest of develop- ment — ^for example, defb sternum, and defgptive formatipn of one or more ribs or oartUages. , , 10. Unstjmmetrical diminution in,i»aeofapaxt of the thorax is produced by any pathological change which reduces the sise of the Sflbjaoent part of the lung. All chronic inflammatory or .congestive conditiofla of the apex of the lung, Whether primary or the consequence of the 00117 oomitant of the formation of tubercle, are at- tended by diminution of the bulk of the part of the lupg which is the scat of the lesion. Con- siderable loss of pulinonary tissue is usually accompanied by falling inwards of the chest-wall over the cavity.' The formation of a cavity is almost invariably attended by ohronic inflam- matory condensation, and this increases the local depression of the chest-wall. In chronic thick- ening of the pleura, the chest-wall at the part is, by'ths contraction of the fibrin, drawn inwards, and the lung subjacent to the' thickened pleura being condensed, the chest-wall is also forced in during inspiration by atmospheric pressure. Hence,' after pleurisy limited in extent it is common to find pennanent flattening of the thoiacio parietes at the base of the chest on the side affected. ' ■ : In cancerous infiltration of the lung, limited in extent, the lung.-tissuc is sometimes so much condensed that the bulk of the cancer and lung arc less than that , of the healthy lung, and the ' It is 8al(J that a very large ilr-cbntalnlng cavity may give rise to local bulging. ; , . .^ DEGENERATION. 883 chest-.wnlls 83 % consequence are flattened over the seat of disease. 11. Vtutj/mmeiric^l localised bulging. If the ribs are, in .relatiop , to ^ the size of the lungs, disproportionately . long,' and their cartilages soft, then one or more of .the cartilages may be knuckled forwards; ttiS cartilage, being compressed between the end of the rib and the sternum, bends in an angle outwards. Although the prominence is trifling, it often causes anxiety to parents and its subject., Local defoi-mity of this kind is occasionally the result of repeated lateral doippression of the chest-wall in the ath- letic sports of young boys, e.g. cricket. AU'the diseases of the chest which are accom- panied by general enlargement of both or one side of the chest, when localised, are attended by local bulging ; thus a cottimon cau^e of abnormal flilness' of the Io*^r' part of the left side of the thoi'ax', posteriorly, is emphysema of the corresponding part of the lung ; a moderate amount of fluid in tiie pleura is attended by ful- ness of the lower part of the chest on the same side. In both these cases the ribs are raised into an abnormally horizontal position ; the chest- walls are not pushed outwards, but the ribs are raised, and the intercostal spaces are to that extent widened. The ribs are put into the posi- tion which gives' the greatest capacity to the thoracic cavities containing the fluid or the enlarged lung.i Local bulging may be prodiioed by aneurism of the arch of the aorta or of the innominate artery; by growths, malignant or other, , within the chest ;: by ohtonio pleurisy with effusion circumscribed by dense false mem- brane ; by hydatids ; or by abscess ;. and in all these cases the ' prominence is due to direct preasure, on the inner side of the chest- wall, and to .changes, in; the chest- wall itself. , Hypertrophy and dilatation of the heart and fluid in the pericardium are attended by fulness ^of the ,pr8ecprdial|, region. The' bulging from these diseases is. miich greater in the phild than in the,adu^t. In these, cases a little of the ful- ness is produced by a more horizontal arrange- ment of the rib^; but when the prominence of the preecordial region is at all considerable, it is the result of the pressure exercised by the fluid or by tbe large and powerfully acting heart on the inner suriace of the corresponding part; of the chest-wall. At the part corresponding to the junction of the first and second bones of the sternum J oppo- site tbe cartilage of the second rib, the sternum projects forward. This prominence is called the aiigle of Ludovibus.' Any impediment to the free entrance of air into the lungs may cause depression ■ of the 'lower part of ^t'lie sternum ; if the ossification of the sternum is not complete at the junction of the first and second bones, undue prominence of this part is the result. Subsequently a formation of bone takes place at this spot, and increases the prominence. William JsiraEE. DEGEirai'BATipH' {degener, unlike one's race ; out 0^ kind). DEFiNiTioir.^The word ' degenerafion,' mean- ing etymologically change or deterioration of kind, ia uaed in pathology for any process by as4 which a tissue or substance becomes replaced by some other, regarded as less highly organised, less complex in composition, of inferior physio- logical rank, or less suited for the performance of its original functions. While some change for the -worse is thus the essence of degenera- tion, it is of secondary importance by what steps this change is effected. It may be by direct chemical metamorphosis, as of albuminous into fatty material; by infiUration of the tissues -with some new material, as in albuminoid de- generation ; or even by siibstittUion of a newly- formed tissue, inferior to the original in organi- sation or in functional efficiency, as in what is called fibroid degeneration. Degeneration is very closely connected with atrophy, since on the one hand it is often caused by imperfect nourishment, and on the other hand may be a stage in progressive wasting ; so that it may be difffcult to draw the line between the two. SoMMABT. — The following kinds of degenera- tion may be recognised: — Mbumitwid, Fatty, Mucoid or Colloid, Parenchymatous, Calcareous, Pigmentary, and Fibroid, with possibly one or two minor varieties of less moment. The two first - mentioned are described elsewhere (see AxBUMiNoiD Disease, and Fatty Degenbbation). 1. Mucoid or Colloid degeneration is iu one sense a physiological process, since it is probably by a partial transformation of the pro- toplasm of epithelial cells into mucin that the secretion of mucus is effected. Mucoid and colloid degeneration are sometimes distiDjTuished. We are unable to recognise any difference except in situation, and this distinc- tion is better expressed in other words. The process consists in the transformation of por- tions, usually albuminous, of the tissues into a semi-transparent homogeneous material, varying in consistency from fiuid to a gelatinous solid, and consisting of altered albuminates with vari- able proportions of mucin, a substance allied to albumin, but differing in its entire insolubility in acetic acid, and solubility in alkalies. All t masses of gelatinous appearance have not this confposition, since the colloid material which fills some ovarian cysts, that of renal cysts, and probably that found in some other cases, is said to contain no mucin. The thyroid gland when enlarged and cystic, as in one form of bronchocele, is a striking instance of colloid degeneration. The enlarged cystic vesicles become filled with colloid material, which plainly results from a transformation of the epithelial elements, and possibly also of some albuminous exudation in the original vesicles. Small masses of colloid material first appear in tlie cells, which become confluent into homogeneous masses. In colloid cancer a simi- la.r process appears to take place, but is rather synchronous with, than subsequent to, the growth of the tumour. The alveolar spaces which in other forms of cancer are filled with cells, here contain colloid material resulting from the metamorphosis of cells, and every transitional stage, from the epithelioid cancer-cell to a homogeneous translucent mass, may often be met with. The stroma is unaffected, and re- mains fibrous. The gelatinous material of eoUoid cancer is stated to contain more mucin DEGENERATION. than that of the enlarged thyroid. It is ins true, tive to notice that this form of cancer usually occurs or commences in parts where epithelium is present, which undergoes the mucous trans- formation and secretes mucus, as in the sto- mach and intestines. When colloid or mucoid transformation affects tissues of the connective tissue group, it is the intercellular substance which appears to be chiefly affected. This change is seen in the mucoid softening of car- tilage which sometimes occurs in old age, where the chondrin undergoes chemical change, and the intercellular substance softens into a diffluent or liquid substance containing mucin. The so-called mucous tissue which forms the umbilical cord, and the vitreous body of the eye, as well as certain foetal structures, consists essentially of a reticulated connective tissue with mucous inter- cellular substance, and the same tissue forms tlie new growth called myxoma, which may therefore be regarded as formed by mucous transformation of connectiye tissue. Its cells are quite unaffected by this change, being either fixed stellate connec- tive tissue cells, or migratory lymphoid corpus- cles. This view explains how portions of other tumours, as sarcoma, enchondroma, and lipoma, are often found to have undergone myxomatous degeneration. All these mucoid or colloid sul)- stances contain mucin with albuminates. 2. Parenchymatous or Granular degene- ration, also called cloudy swelling, is a peculiar change met with in some epithelial struc- tures, especially liver- and kidney-cells, and muscular tissue, occurring only in the course of some infective febrile diseases, especially typhus, enteric fever, scarlatina, diphtheria, pyaemia, etc. The histological elements are found after death to have lost their transpa- rency, and to be fiUed with minute granules, eo that the general appearance is not unlike that of fatty degeneration. The naked-eye appearance of the organs is also not dissimilar ; they are pale, duU, and opaque-looking. This change has been thought to be the precursor of fatty change : but whether this be so or not, it is at once dis- tinguished by the solubility of the granules in acetic acid, and their insolubility in ether. The cause of this degeneration has been asserted to be simply high temperature; still it is notfomid in all febrile diseases. It has also been regarded as a post-mortem change, which is possible^ .but still this implies some abnormality in the tissues during life. Another change.also occurring in febrile dis- eases is waxy or vitreous degeneration of tlio voluntary muscles. They are found after death with little or no striation, and the myosin i> regularly coagulated in lunips. That this is a change occurring after death there can be no doubt; while it is equally clear that this ab- normal coagulation shows some abnormality of composition to have existed during life. 3. Calcareous degeneration consists in the deposition of calcareous particles in the elements of a tissue, or in some inflammat,ory products pre- viously formed. It is more appropriately called calcareous infiltration or deposit. When the normal tissues are thus infiltrated, there is not of necessity any other alteration in the tissues themselves, though the process generally indi- DEGENERATION. cates retardation of the circulation or arrest of tissue-metamorphosis. In the case of inflam- matory products, new-growths, and parasites, as well as in other cases, the calcareous deposit follows on partial necrosis or local death. It is, therefore, if not a degeneration, the consequence or accompaniment of degeneration. See Deposits, Calcareous. 4. Pigmentary degeneration is a name which has been given to the changes produced in a tissue or organ by the deposition or formation of pigment. It is very doubtful whether this should always be described as a degeneration, since this change does not necessarily diminish the vital activity of the part, lower its i)hysio- logical rank, or involve a simpler chemical or anatomical composition. Pigmented tumours do not show less vitality than others, nor is excessive pigmentation of the skin or any organ where pigment normally occurs, neces- sarily an accompaniment of degeneration. On the other hand, the pigmentation of the spleen and liver from intermittent fever, and that which is the consequence of chronic venous con- gestion, are often the accompaniment of fibroid induration, and thus form part of a degenerative process. Pigmentation in general must not, therefore, be identified with pigmentary de- generation. 5. Fibroid degeneration is the name given to a process in which the original tissue becomes replaced by a form of connective tissue. It is also called fibroid substitution or fibroid change. In the early stages of this process we find the tissues penetrated with numerous cells of the lymphoid type, which become slowly organised into connective tissue — at first of the cytoge- nous form, and rarely very vascular. The in- filtrated lymphoid cells are probably chiefly derived from the blood-vessels ; but some may be, as theory teaches, the descendants of tissue- cells. The process is essentially chronic inter- stitial inflammation {see Inflammation). Since the final result of the process is that tissue of less physiological value is substituted for the original, the process may be described in general terms as a degeneration, though it is not an actual metamorphosis of tissue. It finally leads to induration, contraction, and partial atrophy. J. F. Paynb. DEGLTJTITIOH', Disorders of.-J-Before describing the disorders of ' deglutition or swal- lowing, it is necessary to stjite briefly in what this physiological act consists, and how the process is performed. Phtsioloot of Deglutition. — The act of deglutition is commonly divided into three stages. The first is a voluntary effort, accom- plished by means of the tongue and the muscles of the cheeks and mouth, as fkr'back as the ante- rior arch of the fauces. The second stage is an involuntary act, though certain voluntary muscles are engaged in effecting it ; and it is accomplished by the action of those muscles whose duty it is to retract the tongue, to raise the larynx and close the glottis, to lift the soft palate, to contract the fauces and bring the tonsils in contact with the bolus of food, to close the posterior nares, and to raise and contract the pharynx. DEGLUTITION, DISOBDEES OF. 335 Then the food passes into the (Esophagus or gullet, when the third stage is entered upon; and as the morsel passes into this tube, a pro- gressive uudulatory or peristaltic movement of the gullet is produced, by which the bolus is propelled into the stomach. Definition.— ^Ariy condition which interferes with the perfect integrity of this physiological process constitutes a disorder of deglutition. The general term which is commonly applied to this condition is Dysphagia or Deglutitio Im- pedita, as it is sometimes termed. But, in actual fact, such conditions will be found to be dependent for the most part on some other morbid state of the structures immediately concerned in the act of swallowing, or qf those in close proximity to them. Yet, although dysphagia must, as a rule, be re- garded merely as a symptom of some more or less serious disorder, still it may be convenient and useful to examine the subject somewhat more in detail than can be done in the consideration of those affections in which it frequently plays so prominent a part. . JJtioiogt. — All affections of the throat modify in some way the power of swallowing, and render the act of deglutition painful and diificult. Thus: — 1. We meet with it as one of the symptoms in acute catarrh of the pharynx, in tonsillitis, and in ulceration of the throat, which disturbances are dependent upon some alteration in the mucous membrane, the submucous cellu- lar tissue, or the muscular tissue. 2. Similarly, diseases of the larynx may give rise to disorders of deglutition; such as laryngitis, inflammation of the perichondrium of the cartilages, and laryngeal polypi. 3. Specific diseases, for ex- ample, phthisis, syphilis, cancer, scarlatina, measles, and croup, are another fertile cause of difficulty of swallowing, owing to their affecting the throat in various ways. 4. So also are neiv vous affections, for instance, post-diphtheritic paralysis, hysterical affections, general paralysis of the insane, progressive muscular atrophy, and gldsso-laryngeal paralysis. 5. Affections^of the salivary glands, such as parotitis, may inter- fere with deglutition. 6. Esophageal disorders, whether functional, or causing organic obstruc- tion, are important causes of dysphagia. 7. Difficulty of deglutition may result from pressure upon some part of the passage, as by an aneu- rism of the thoracic aorta, a solid tumour, whether malignant or benign, or a retro-pharyu- geal abscess. All these causes, though in differ- ent degree, offer, some impediment to the act of deglutition. Symptoms. — Although diiliculty in the act of swallowing is the essential symptom in many and various affections, yet this differs greatly in degree, as well as in the attendant phenomena, according to the pathological condition of the parts involved. Thus, when irritation of any kind is met with in any part of the track through which the bolus of food has to pass, then the act of deglutition is attended merely with more or less pain, which in such cases constitutes the sole difficulty in the process. When, however, the calibre, of this pction of the alimentary canal is reduced by disease affecting its own structure, or when . it is encroached upon by morbid growths or other disease in its immediate 336 DEGLUTITION, DIS0EDEB8 OF. vicinity, a mechanical impediment is pet np, which necessitates a certain amount, of voljintji^ -effort to accomplish the act. This supplementary aid is usually sufficient to propel the bolus on- wards, and deglutition, though slower than in health, and usually attended with pain, may be.^uecessfully performed. It occasionally hap- pens, however, that the obstruction is so great as to, prevent .the passage of at' least the larger portion of the food downwards, anjd, regurgita- tion takes place through the mouth or nostrils. A siniilar result is OTonght; about when para- lysis affects any portion of the miiseular struc- tures concerned in the act of swallowing, but obviously in a different manner. , For example, in post-diphtheritic paralysis, in^, consequence of the implication of the soft palate and neighbour- ing structures in this loss of power, the food, instead of passing into the gull et, returns through the posterior nares. „ The dysphagia occasionally observed in hys- terical persons, and which appears to. partake of the nature of spasm, differs essentially from those forms already described, in the fact that it is not a constaqtphenomenoQ. In addition to those varieties of dysphagia dependent upon morbid Conditions of theapparST tus concerned in.the act, of swallowing, another kind may also be induced by the nature and form of the articles partaken of. Thus, irritant, corrosive, and very hot substances may readiiy give rise to difficulty in swallowing. In like mannerdysphagia of an urgent character is often caused by the, impaction of a large bolus of un- masticated food in the oesophagus. TjKBATMEirr.—TThiswillmauifestly depend upon the recognition of the cause which gives jise to the impediment in swallowing. .Cases of simple catarrh of the mucous membrane of the throat, and those produced by the action of irritant substances generally, yield, after a short , inter- val, to the use of bland articles of diet and demulcents, such as olive oil, milk, linseed tea, &c. It must, however, be borne in mind that permanent stricture of the (esophagus may be the result of causes such as those l^st mentioned. Of course, when abscess is the cause of the dysphagia, the evacuation of its contents will give immediate relief. In th&,t form of dysr •phagia dependent upon; diminution of the calibre of t^e oesophagus,, the question of its treatment by the use of bougies or sf omachrtubes should be considered.- See OSsoPHAQns, Diseases of. : Tho , dysphagia , dependent upon specific dis- orders of the larynx, such as that occasioned by phthisilj syphilis, cancer, &c., may often be greatly mitigated by the use of warm medicated sprays of a sedictive character, such as bromide of ammonium, chlorine water, or other agents. In cases acknowledging a nervous origin, the treatment must bear reference to the general nervous disorder of which the dysphagia is but a symptom. Thus hysterical dysphagia may be speedily removed by the appHcation.af galvanism in the neighbourhood of the (esophagus. Post- diphtheritic dysphagia usually disappears as the health of the patientimprovesiand isto be treated by, the administration of nervine tonics, such as strychnia, iron, and quinine. C. MuiBUEAD. DELHI SOBE. DELHI SOBE OB BOIL.— Svsraf, Aleppo : Evil } Mycosis . Cutis Chro-iica (V. Garter) ; Lupns Endemieus,(IiPwi3 and Cunuing. ham) ;j Oriental Sore (Fox). Fr. Suuton cfAlep ; Geri Bfiule von Alep. DEFiNiTioif.^An induratcd,indolent, and veiy intractable sore ; papular in the early, encrusted or fungating in the advanced stages ; spreading by "ulceration pf skin; single or multiple; and often occupying extensive surfaces of the expieed parts of the body, such as the face, neck, and extremities. It is capable, if inoculnteil, of re- producing the disease ; and it also affects doga and ho:rses. Geogr«^tcai. Distribution. — This disease occurs in India, especially thp North west Pro- vinces, Punjab, Cabuland Sciude, Persia, Ara,bia, CretOj the Sahara :of Africa, perhaps China, and doubtless wherever certain peculiar conditions of soil and hot . climate co-exist. Though called Delhi boil, it is neither a, , fumncnlus, nor is it peculiar to that city. The Scinde boil, the sores of Eoorki.e,, Moultan, ,Lfihore, Meerut, :other (jrowded Indian cities, and Aden, are problbly only varieties, if not identi'-al. The same may be said of the Bouton d'Alep, of Biskra, Bus- sorah, Baghdad, and Crete, , Slighj: differences may exist, but essentially they are the same disease. The Teman and Cochin China sores are probably varieties, as are other indolent in- durate4 and intj'actable sores occurring in per- sons of impaired health, residing in hot and malarious climates, who use certain hard waters, and in whom there is neither syphilitic nor strumous taint. Mxioj-osx AND Pathoi;o(jy. — Drs. Fleming and Smith, V. Carter, and Lewis and Cunningham give the best account of the disease. Though called a local disease, it is probable that the state of the health has much to do wilhit? produorion, certain conditions of climate, soil, and especially of drinking water being concerned. Fnmnculi of a severe and painful though different character are prevalent in hot climates at certain seasons of the year, in enervating and malarious climates like India, especially after the rains, i.e. towards the termination of the most exhausting season, when the vital powers have been depressed during the preceding months, and the fuprt'ons of the liver and , spleen are impaired. The blood, imperfectly elaborated, and not freed frnm ex- crementitious matter, is then in a condition in which it not only ministers imperfecjfely to nu- trition, but is prone to fibrinous coagulations, which cause capillary embolism, giifi'ngi rise to local starvation and death of minute portions of areolar tissue in or under the integument. These result in suppuration, which is set up for the purpose of getting rid of the dead fragment or core. An analogous, though perhaps Sot pre- cisely similar pathological condition liiay be con- cerned in the causation c(f the Delhi sore, and is not incompatible with an otherwise fairly good condition of the general health. Water, soil, food, bites or stings of insects, pfirasites.iinsani- tary conditions, such as exist in crowded native cities, have .all been charged ^ with causing tho disease. Improved hygiene, planting of trees, and change of 'water, foo 1,and locality, have all been credited with benefit in the treatment of it. Thr DELHI SORE. fact that this peculiar tbnn of sore manifests itself under similar cUmatio conditions in other parts of the world, Tifhich, it is to be noted, are generally those of the more arid regions, and that it occurs most frequently at the most eshausting season, seems to point to a constitutional state as a pre- disposing cause. The disease is not confined to human beings ; in Delhi it has been observed that dogs are very liable to be affected, especially in the nose, and this, from the position of the sore, has been ad- duced as strong evidence in favour of the theory that it is due to the presence of a parasitic ovum which finds its way there from the water. In some districts other animals are affected; arid it seems probable that the indolent, indurated, and intractable sore that horses are liable to in India, called BurmtUe (Eain Sore) is of the same character. Further investigation into the cau- sation and pathology of Delhi boil is needed, especially with reference to the action of drink- ing water, and the nature of the structures that form the essential constituents of the disease. Akatomioal Chakactees. — When the Delhi sore is cut into, yellowish points are seen, con- sisting of minute cellular growths, which have been described by Dr. Smith as the ova of a parasite {DiMoma), ai}d by others as of vegetable origin, but are probably the result of cell- growth, connected with the hair- and gland- follides, perhaps an abnormal development of connective-tissue corpuscles, or an imperfect form of granulation. After ulceration has disinte- grated the siurface, mycelium or other low forms of organism may be present ; but it is a question if these be the essential cause, and not rather an accident of the disease, introduced from vrithout. Dr. V. Carter refers Delhi boil to a parasitic organism, consisting of spheroids and mycelium, which occupies the distended lymphatic ves- sels in and around the sore, arranged in open and angular meshes, the free ends giving off conidia which multiply and reproduce. Pale, round or stellate granulation-cells are found ; numerous bright orange-tinted particles, arranged, as sphe- rical or ovoid groups disseminated throughout the tissues of the tumour. These, it is consi- dered, are the. fructification-stage of the fun- gus. Lewis and Cunningham describe lymphoid nucleated cells, the products of a condition which they consider as identical 'writh that of lupus, and which they ascribe to the action of the chemical constituents of certain hard waters. SmpTUMS. — Delhi sore commences as a small pink and reddish papule, like a mosquito bite, which gradually extends, generaUy around a hair-follicle as its centre. This is elevated, and after a time desquamates. There is itching and a- stinging sense of pain ; on presfiure it is somewhat boggy. The progress of the disease is slow, often occupying several .wqeks, during which time it assumes a Bem,i-transparent ap- pearance, with blood-vessels ramifying near the surface. A vesicle then rises, biirsts, and gives exit to an icior which forms a crust ; under ihis, suppuration and ulceration take place and advance until, by the coalescence of several pa- pules and destruction of skin, an indurated sore is formed, which is either crusted over or fun- Kates. The sore gradually invades the surrounding 22 DEMENTIA. 337 parts, and destroying the integument, may give rise, especially on the face, to deformity from cicatricial contraction ; and from the irritation and the pain it causes, may, when the number and extant of the sores are large, seriously com- promise the health. An ordinary boil or abra- sion may assume these specific characters. The disease is regarded as contagions, and apparently may be produced by inoculation of the specific cell-matter, though not by the pus which formt on the surface. Tbbatment. — Preventive. — Cleanliness of per- son, clothing, and habitation, good food, the use of pure drinking water, and careful attention to the sanitary condition of the locality, — avoiding overcrowding and contact with the disease in men or animals, — are the best means of prevent- ing Delhi soie. Curative. — Change of locality, when practic- able ; in some cases early destruction of the sore by the potential or actual cautery; the ap- plication of metallic astringents, iodine, carbohc acid lotion ; pressure ; attention to the state of the health, and any ailment that may be pre- sent ; tonics and nutritive diet, and especially change of drinking water ; and change to another climate, — are the most effective measures. In the advanced conditions of the disease similar measures are indicated. The sore, if too extensive to be destroyed, should be dressed with stimulating and astringent applications. Soothing measures are indicated if there is pain. Hack wash, sulphate and carbolate of ziuc, copper, Giirjon oil, and lime water, with change of climate, and the use of tonics, ■will generally prove efficient. Joseph Faybeb. DSIiIBIUK {deliro, I rave). — A derange- ment of consciousness, characterised by inco- herence of thought, and evidenced by various expressions and actions. See .Coitsciouskess, Disorders of. DBIiIKITTM TBEMEWS {delirium tre- mens, trembling delirium). — A form of acute alcoholism, chiefly characterised by delirium and tremors. See Alcoholism. DEIiTTSIOM' (ddudo, I deceive). — A false belief in some fact which almost invariably con- cerns the patient, of the falsity of which ho cannot be persuaded, either by his own know- ledge and experience, by the evidence of his senses, or by the declarations of o^ers. Such delusions, when distinguished fSoin merely erroneous judgments upon abstract questions, generally indicate insanitj'. See CoNSCiousiiESS, Disorders of. DEMEH'TIA((fe, without, and meras, a mind). — Stnon. : Fr. Dlmence ; Ger. Blodsinn. Definitiok. — A mental weakness, or a defi- ciency rather than an aberration of intellect, depending for the most part on some antecedent brain-disordpr, such as apoplexy or epilepsy, or being the sequel and termination of various forms of insanity. It may also be congenital, deserving rather the name of idiocy; or nay be due to senile decay. 338 DEMENTIA. 1. Acute Primaxy Dementia.— There is a form of insanity tnown as primary or acute dementia, -wWeh comes on rapidly without any preceding disorder, is accompanied by the most profound vacuity and abeyance of all the mental faculties, yet yields to treatment and disappears, leaving the patients sane. JEtiomoy. — The patients are yonng persons, boys and girls, — ^more frequently girls. The complaint is seldom seen in any case beyond the age of 30, and chiefly in those under 20. It seems to be a collapse of all mental power, due to great physical weakness and deficient nerve- force. Owing to imperfect dfevelopment, to bad food and living, or to the patients having outgrown their strength, the mental condition becomes so weakened that, with or without some moral cause, as a fright or a scolding or something apparently more trivial, or after some illness slight or severe, they suddenly or gradually present that condition which is now to be described. If the immediate exciting cause is some mental shook or fright, the symptoms may come on rapidly. If they are due to ill-health or some protracted exhausting occupation, the access maybe gradual ; and if it is set down to sulkiness, temper, or idleness, the measures adopted for the correction of the latter may quickly indicate the real state of things. Symptoms. — Notliing can appear more hopeless than the appearance many of these patients pre- sent. The face is vacant, with a fatuous grin, and often the saliva dribbles continuously. The suf- ferer sits motionless and lost, or automatically wags the head, snaps the jaws, or moves the limbs for hours together unconscious of fatigue. Or if a limb is placed in any position, it is retained there for a time in a way that no effort of will could accomplish. There may be a repetition of some word or sentence, but all conversation is abolished, and the patient has to be fed, washed, and tended lite a baby. The physical condition of these patients is peculiar, and corresponds closely to the mental. The heart's action and the circulation are so re- ducedin strength that the blood in the extremities is stagnant. Hands and feet are blue with cold even in the heat of summer. In cold weather they are covered with chilblains, and great care must be taken, otherwise these will give rise to obstinate sores. The tongue is pale and flabby, the pupils are dilated. There is no rapid emacia- tion, for the waste here is not great ; neither Is sleep absent, as in mania, but it is irregular and uncertain. PiTHOLOSY.— The external physical manifesta- tions sufficiently indicate the condition of the brain in these patients. It is the very opposite of that in acute sthenic delirious mania. In the latter there is an excessive discharge of nervous force, an hyperaemic state of brain, and rapid brain- circulation, the whole leading in a short time to death by exhaustion if relief does not come. lu acute dementia we see the very opposite. The brain-action is reduced to the lowest point, and the_ circulation is stagnant, as in the extremities, giving rise to passive congestion and osdema. CoTJESB, Teeminations, AND. Pkoonosis. — In acute dementia there is no sudden exhaustion; but death, if it occurs, is caused, not by the brain-disease, but by a general failure of the bodily strength, or by some low form of lung- disease — phthisis, pneumonia, or gangrene. Death, however, in this disorder is the excep- tion. When taken in time and properly treated, the majority of these seemingly hopeless cases recover, and recover perfectly. TEEATMmrr. — The treatment of acute dementia may be candied out in a family, or even at homo, if means are ample, and if the necessary mesr sures are strictly enforced. But it may be neces- sary to feed the patient by force, and that for a considerable time, and relations do not always care to enforce this to the extent required. Abundant nutrition is imperatively demanded in order to restore the force that is so greatly in defect, and unless abundant nutrition is adminis- tered, there will be no recovery, but the patient will die, or sink into permanent dementia. There is not as a rule violent resistance to food, but it may be kept in the mouth without being swal- lowed, and care must be taken in feeding, even if a stomach-tube be not necessary. Food should be given frequently, and so a habit of taking it engendered. Stimulants, wine and brandy, wll be necessary, especially in the early stages. Equally necessary is warmth; an amount of heat is required which to those in health would be oppressive, for the greatest heat of summer fails to warm the hands and feet. Warm clothing must be provided, and the circulation aided bya short sharp shower-bath, cold or tepid, and plenty of friction afterwards. Exercise is useful for the same purpose, but this is to be taken under proper supervision, for it must not be fatiguing, and due regard ought to be had to the debili- tated state of the individual. In addition to the stimulus of the shower-bath, that of elec- tricity is of great use in acute dementia. Here, and in certain cases of melancholia, marked benefit follows the application of the constant current. Of drugs the most useful appear to le steel and quinine. The former, in this as in almost every form of insanity, is a most valuable tonic: the choice of the particular preparation should depend upon the state of the patient' at the time. 2. Chronio Primary Dementia. — Dementia, however, may be primary, yet may not be that just described. It may come on gradually;' or suddenly without previous mental affection, hut is in such cases connected almost invariably with disease of the brain. Its first and most prominent symptom is loss of memory. In connexion with apoplectic or epileptic attacks, or after years of drinking, the memory is found defective. This may appear quite suddenly, or may be noticed to come on gradually, being at first so slight as to cause little alarm. It may vary at different times. If a patient is kept from alcohol, the memory may gain strength, and if epileptic attacks are reduced in frequency, the same thing may happen. The prognosis' in all such cases is unfavourable, for loss of memory points to decided deterioration of brain." Apart from loss of memory, symptoms of dementia or weakness of mind are occasionally fouhd as the first indication of mental unsoundness, followiiiga fright or shock or some severe illness. If they assume the form of acute dementia, we may have DEMENTIA. hopes that they ■will pass a-vray, but if with little disturbance of the bodily health the mind be- comes ureaker and weaker, the hopes of recovery are small. 3. Seoondary Dementia. — Of dementia which is the sequel to prior mental disorder, such as mania and melancholia, little need be said. It varies in degree, but it is not in our power to remove it. It may be in our power, how- ever, to ameliorate in a great degree the condition of such patients when, as ia frequently the case, they are found in a very neglected state. Their friends think that nothing can be done or need be done, and they are allowed to lie in bed, often in a filthy condition, or roam about and get into mis- chief for want of care and skilled attendance. Many demented patients have far more mind than is generally imagined by the uninitiated, and can be taught to be cleanly, to take their meals in an orderly fashion, and to keep themselves tolerably neat. They are susceptible of amuse- ment, and open to reward for good behaviour. The vital powers of demented patients are low, and they sufiFer much from cold. In winter their minds like their bodies are enfeebled, and with warm weather they recover somewhat of their energy. There is a tendency in many of these patients, especially women, to become very fat, and in this condition they are subject to bron- chitis, and many succumb to acute attacks of this disorder. They require warmth and good diet, for'it is difficult to make them take sufficient exercise. Females, in the writer's experience, are more prone to drift into dementia than males, Tho latter present various types of chronic mania, with well-marked delusions ; but, among private patients at any rate, there are fewer of the hope- lessly demented than among the female inmates of private asylums. One cause of this may be that the mortality amongst males is greater, and thus fewer are left to reach the demented stage. Gr. F. Blandfobd. DEMODEX (Sejuas, a body; and Sif, a timber-worm). — ■ A genus of acari'ne parasites, established by Owen for the reception of the human pimple mite (D. fotticvloruTTii), which is sometimes spoken of as the Simonia or Entosoon foUiculorum. It infests the sebaceous follicles, especially those situated upon the sides and alse of the nose. The body is vermiform, owing to the great length of the abdomen, but the entire animal rarely exceeds the J^ of an inch from head to tail. Gruby and others have succeeded in inoculating dogs with this parasite, which has also been found in mange- affected animals not previously subjected to experiment. In man, when occurring in large numbers, they cause the formation of prominent pimples, which often present an unsightly appearance. Each whitish spot or enlarged follicle, presents to the naked eye a terminal black point, and it contains not only full-grown animals (having their tails directed towards the opening) but also eggs, larvse, and exuviae. Their presence rarely gives rise to inconvenience , other than that residting from unsightliness. Infected persons, however, BTC extremely glad to get rid of them, and this niny be done by the application of mercurial DENGUE. 339 ointments, by the frequent use of a corrosive sub- limate lotion (2 grains to 1 ounce of water), or, as the writer has found, by rubbing-in glycerine of carbolic acid after warm water fomentations. A coarser method of treatment consists in evacua- ting the pustular contents by small incisions and pressure. By forcibly bursting the foUicleg and squeezing out the contents small ugly scars are apt to be subsequently formed. See Aoaeos, T. S. COBBOLD. DEMITLOEK-TS {demulceo,! stroke softly). Definition. — Substances which, soften, pro- tect, and soothe mucous membranes. They are generally of a mucilaginous character ; and when applied to the skin are termed emollients, Encmeration. — The demulcents in ordinary use are — Linseed-tea, Gum, Starch, Bread, Honey, Figs ; Linseed, Almond, and Olive Oil ; Glycerine, White-of-Egg, Gelatine, and Isinglass. Action. — The chief action of demulcents is a mechanical one, in forming a smooth, soft coat- ing for an inflamed mucous membrane, and thus protecting it from external irritation. T. Laudbe Bbunton. DEITGrtTB. — Synon. : Dandy fever (West Indies); Three-day fever; Break-bone fever; Fr. and Ger. Bengue. Definition. — An infectious, eruptive fever, commencing suddenly, and characterised by severe pain in the head and eyeballs ; swelling and pain in the muscles and joints, prone to shift suddenly from joint to joiiit ; catarrhal symptoms ; sore-throat ; congested conjunctivae ; and affection of the submaxillary glands. The disease may remit, and is liable to relapse. Nathbal Histoet and Geogkaphicai. Dis- TBiBUTjoN.^Dengue occurs epidemically and sporadically in India, Burmah, Persia, Egypt and other parts of Africa, North and South America, and the West Indies. It is not known in Britain. Epidemic visitations of dengue, ex- tending over wide tracts of country, occur at considerable intervals, and probably depend on certain unknown atmospheric and cosmic con- ditions that favour its development. JExiOLOGT. — ^Dengue attacks persons of all ages, from infancy to extreme old age. It certainly is infectious, as has been proved by many cases in which the disease has been con- veyed from person to person. Symptoms. — Those characteristic of dengue are the presence of severe continuous arthritic and muscular pains ; great debility and prostra- tion ; the occurrence of an initial and a ter- minal rubeoloid or scarlet rash ; fever, which ia subject to remissions and relapses; the possi- bility that convalescence may be tedious and painful, and complicated by the continuance of general cachexia, pain and swelling of joints, enlargement of glands, orchitis, weakness of eyes, deafness, visceral disease (such as diarrhoea or dysentery of a chronic and intractable charac- ter, and hepatic derangement) boils, carbuncles, and perhaps insanity. In the female, uterine haemorrhage and miscarriage may occur. The invasion, of dengue is usually sudden, the patient feeling well up to the period of attack. The earliest symptom is severe pain in some 340 joint, probably of a finger, -which rapidly extends to all the other joints and bones ; and this pain during the progress of the disease often passes from one joint to the other by a sort of raeta^ stasis. Sometimes there is a period of prelimi- nary malaise, of one or more days' duration, marked by anorexia, a sense of weariness and languor, giddiness, nausea, chilliness or rigor, severe pain in the head — localised or in the eye- balls, and pains in the body, limbs, and joints, notably of the fingers and toes. The attack is often, however, strikingly sudden, as was fre- quently seen in the last Calcutta epidemic, com- mencing with violent pains and swelling of the joints, or severe pains in the head, eyeballs, neck, and back. In some epidemics certain phenomena are more prominently marked than others. The eruption commences on the third day. The fever is accompanied by redness of the face, which is puffy and swollen; sore-throat; con- gested conjunctivEe ; and a general redness, like the scarlatinal rash, extending over the whole body. The tongue is red at the tip and edges, and loaded with white fur, through which the red papiUaeprotrude. Thepulse is rapid, ranging from 102 to 120, or even 140 ; respiration is hurried ; and the temperature rises to 103° or even 105°. These symptoms mark the occurrence of the initial fever and rash, and endure for a period varying from one day to forty-eight hours. After this the rash disappears, the fever sub- sides', and the remission lasts for a period of two, three, or four days. A recurrence of febrile symptoms then takes place, accompanied by a second, or terminal rash. This differs in character ftom the first, resembling a rubeoloid or even an urticarial eruption, often showing itself first on the palms of the hands, and in some cases resulting in profuse desquamation of the cuticle, though it may sometimes be so slight as to be, barely perceptible. These symptoms gradually subside, leaving the patient weak, ex- hausted, and often still tortured by swelling and pain of the joints, especially the smaller ones, which may continue in this state for weeks, making convalescence tedious and painful. Or there may be repeated relapses, prolonging the suffering and protracting recovery. Vaeieties. — The symptoms vary in different cases, as to the character of the rash, the tem- perature, and the muscular or osseous pains. The rash not only varies considerably in co- lour, diaracter, and duration, but it is sometimes almost absent ; in other cases it is attended with so much'hyperaemia and action of the skin that excessive desquamation results. This hyper- semia also' sometimes expresses itself by haemor- rhage from the mouth, nose, bowels, and uterus. The fever is sometimes accompanied by de- liriimi, or in children by convulsions ; in the latter, indeed, these occasionally initiate the disease. Dengue occasionally assumes a malignant form, where the amount of poison received has been overwhelmingly large. Dr. Charles says : 'Drowsiness may have passed into coma; the temperature verges on the hyperpyretic ; the heart fails, and the lungs are cedematous ; while the whole surface is highly cyanotic These canes DENGUE. have been popularly termed " black fever," ana are justly much dreaded.' Happily such cases are rare. Again, there are very mild forms of the disease, in which the patients are scarcely ill, and where it is not easy to decide as to their exact nature ; ' A trifling sore throat and slight malaise may be all you can lay hold of till the terminal rash appears to show you what yon have had to deal with ; and even this may not be seen.' COUESE, DCKATION, AND COMPLICATIONS.— The period of incubation of dengue is prdbably from five to six days ; it may be a day or two more or less in some cases. In simple and uncomplicated cases the average period for the duration of the disease may be taken as about eight days ; but it is frequently prolonged over weeks, and recovery is slow and painful; the constitution often being so much shattered that complete restoration to strength and vigour does not occur for months. It is rarely fatal. Selapses are liable to be frequent, and the patient may suffer more than even a second or a third relapse before recovery. Some of the sequeliB already mentioned may remain to torture the patient and retard his recovery. Albumen is occasionally present in the urine ; but it is not, as in scarlatina, espe- cially in the cases of children, a frequent or dangerous result of the disease. DiAONosis. — The distinction betwixt scarla- tina and dengue is well marked ; though during the outset there is considerable resemblance between the two diseases. There is a high temperature at first in both, but it is more quickly attained, and is transient in dengue ; in scarlatina it endures for several days, whilst in dengue the fastigium gives a temperature of 103°, or even up to ] 05° or 107°, and this being attained it rapidly declines. It is exceptional to find a temperature above 102° maintained in dengue. In scarlatina the period of decline ex- tends over several days, and is marked by slight exacerbations in the evening. In dengae it occupies a few hours, and the temperature may even fall below the normal standard. The severe muscular and arthritic pains of dengue do not occur in scarlatina ; and the pulse in the latter is much more rapid in the early stages than in the former. The initial rash in dengte occurs sooner than the eruption in scarlatina. Prognosis. — ^An attack of dengue does not confer absolute protection from a recurrence of the disease, though it does so to a great extent. Treatment. — This is a specific fever, and has to run a certain course. The treatment is simple, and if judiciously directed mitigates the sufferings, and materially aids recovery. . Neither emetics nor active purgatiTe|i, are necessary. They do no good, but increase the weakness and aggravate the suffering by the muscular movements necessarily induced. Mode- rate action of the bowels is advisable, followed by a warm carminative aperient, or an occasional dose of calomel, rhubarb, or colocynth, especially if the bowels remain confined, to which there does not appear to be any peculiar tendency, though the evacuations may be dark and often slimy, and confined at the outset. Salines, such as the acetate of ammonia, or citrate of potash, DENGUE. with nitric ether, combined ■with aconite, are good during the pyrexia. In cases of very high temperature (105° to 107°) Dr. Charles suggests cold-sponging as beneficial ; he recommends it when 105° is reached. The danger to life of such a high temperatui'e during the intense heat of the hot months in India is great ; and it is then that cold sponging or the cold bath is indicated. Belladonna seems to confer great relief in this disease ; ten to fifteen drops of the tincture may be given, and two or three such doses at intervals of an hour will sometimes produce excellent effects, and afford much relirf. The extract may be given if preferred, in doses of -jne-third of a grain; or the juice in similar doses to those of the tincture. For the pains and nocturnal restlessness, morphia or Dover's powder may be given. Liniments containing opium, belladonna, and chloroform are service- able as external applications to the spine, back, and joints. Tonics, and a carefully-regulated nutritious diet, are also indicated, and depletive measures must be avoided. The tonics should be of the bitter vegetable kind, such as gentian and ca- lumba; with these may be combined a small quantity of quinine, with a mineral acid; or, n some cases, the dilute phosphoric acid, com- bined with nux vomica or small doses of strych- nine. ftuinine is given more for its tonic than for its antiperiodic effects ; though, where there is a tendency to relapses, the ju(£cious administra^ tion of five- or even ten-grain doses may be bene- ficial in arresting them. Bromide of potassium is recommended by some authorities, and es- pecially when convulsions occur in children. Alkalies, colchicum, and other remedies in use in rheumatism have been found to have little, if any, effect in relieving the pains of dengue. As to wines, daiet is probably the best, but others may be given. For the irritation of the skin, which is some- times very troublesome, the application of cam- phorated oil, and the use of warm baths have been siiggested. As in so many other diseases, especially those that occur to Europeans in tropical climates, complete restoration to health is likely to be expedited and promoted by change of air ; and if the cachexia be severe after a prolonged attack of the disease, return to the patient's native climate for a season is desirable. Joseph Fateeb. DENTITIOIT, Disorders of. — Svnon. : Teething; Fr. Troubles de la dentition; Ger. Zaknm. Gbnbrai. Eemakks. — The period of cutting the teeth has been always recognised as a critical time, during which the health of young children is especially liable to become disturbed ; and it has been a common practice amongst mothers to attribute every illness occurring in early life, from the irritation of scabies to the distortions of rickets, to the same baneful influence. The evolution of the milk-teeth is no doubt attended with some irritation, especially aa at this pe- riod the follicular apparatus of the intestines is DENTITION, DISCED ERS OF. 341 undergoing considerable development and we know that, on account of the impressibility of the nervous system in young children, any irrita- tion is apt to be followed by general disturbance. It is no doubt also the case that local functional derangements are frequent at this period, but it is often unfair to atti-ibute these diredtly to the irritation of an advancing tooth. One of the most common direct results of teething is py- rexia, which may be intense ; and a feverish child is particularly susceptible to impressions of cold, and to the irritation of unsuitable food. Catar- rhal attacks coming on at this time need not be therefore the immediate result of the condition of the gum. It is at least equally admissible to attribute them to the ordinary causes of such derangements acting upon a body rendered for the time peculiarly susceptible to injurious in- fluences. This view is supported by the fact that diarrhoea, which is a very common compli- cation of dentition, is especially frequent during the warmer months, when the temperature is apt to undergo rapid variations, while the dress of the child remains unchanged; and is far less commonduring the winter, when the temperature is more uniform, and the child is more carefully guarded against the cold. As a rule, the first milk-tooth appears in the seventh month after birth ; but dentition may begin at an earlier period. It is not rare for an infant to cut a tooth at the age of four months, and occasionally at the time of birth one tooth is found to be already through the gum. In cases where the ordinary timS of weaning is anticipated, a pause generally ensues after the appearance of one or two teeth, and further den- tition is delayed until the usual age. Constitu- tional conditions influence the time of teething. Thus tuberculous and syphilitic children cut their teeth early, while in rickety children the teeth are very slow to appear. In the majority of cases the teeth pierce the gum in the following order — lower central inci- sors, upper central incisors, upper lateral incisors, lower lateral incisors, first molars, canines, back molars. A child of twelve months old should have eight teeth and be cutting his first molars, and the whole number (twenty) should be through the gum soon after the end of the second year. The order given above is not adhered to invari- ably. The incisors are often cut irregularly, and the first molars may precede the lateral incisors. The canines seldom or never precede the first molars. Some infants suffer more than others from the cutting of a tooth, and it is not always in cases where the eruption of the teeth has been delayed that dentition, when it occurs, is attended with special inconvenience. On the contrary, in severe rickets, where the delay is great, the teeth are often cut with remarkable ease. SiMFTOMS. — The phenomena which may be looked upon as natural to the process of denti- tion are salivation ; swelling of the gum, which becomes more and more tense, hot, and painful ; slight general pyrexia, with flushing of one or both cheeks; irritability of temper; and some de- gree of restlessness at night. These all subside when the point of the tooth appears through the gum. The complications not necessarily S42 DENTITION, DISOEDEES OF. attendant upon the process are high fever; in- flanunation of the month and aphthae ; vomiting (gastric catarrh) ; diarrhoea (intestinal catarrh) ; cough (pulmonary catarrh); various eruptions of the skin, -vrith, sometimes, swelling, and even suppuration of lymphatic glands ; and certain troubles of the nervous system, such as convul- sions, squinting, &c. The peculiarity of the pyrexia of dentition isits irregular character. It is often higher in the morn- ing than at night, and varies in intensity in a remarkable manner from day to day. A tempera- ture of 104:° Pah. at 8 a.m. is not at all uncommon in a teething infant ; indeed such an amount of fever in the morning should alone lead us to inspect the mouth, as few diseases are marked by so much pyrexia at that hour of the day. It is important in practice to bear in mind this simple cause of elevation of temperature, for any disease in a child is apt to be complicated by teething, and much needless anxiety may be occasioned by overlooking the condition of the gum. We must not, however, in every case where the g:nm3 are swollen and tense, rush to the con- clusion that they are the sole cause of the symptoms, for the most serious cerebral disease may co-exist with the eruption of a tooth. Thus, to take an example : — ^if we find cerebral symp- toms to supervene in the course of dentition, we must most narrowly scrutinize their character, before passing them over as merely harmless indications of the general disturbance. Head- ache, delirium, vertigo, startings, twitchings, and convulsive attacks, may merely indicate functional disturbance of the brain such as is common to many disorders, and these phenomena are not necessarily symptomatic of cerebral disease ; but if the bowels become obstinately confined, the pulse slow and irregular, and the respiration un- equal and sighing ; and if in addition there be photophobia, with sullenness and tendency to drowsiness, we may conclude that something more than mere functional derangement is pre- sent, and that there is every reason to suspect the existence of tubercular meningitis. Tbeatment. — The treatment of the complica- tions which occur during dentition must be con- ducted upon ordinary principles. Aphthae of the mouth are readily cured by the administration of rhubarb and soda, and the application to the mouth of a solution of chlorate of potash or borax in glycerine (ten grains to the ounce). Perfect cleanliness is, however, necessary, and the child's mouth should be washed out each time after taking food with a piece of soft rag dipped in warm water. Vomiting is best checked by clearing out the stomach with an emetic of ipecacuanha wine, giving a tea-spoonful every ten minutes until sickness is produced. Afterwards a few grains of carbonate of soda may be given with one drop of liquor arseni calls in a tea-spoonfnl of water three times a day. Diarrhoea should be treated on the same principle : — first a dose of castor oil to re- move irritating secretions from the bowels, then a nuxture containing chalk and catechu, or oxide of zinc (one grain to the dose). If afterwards the motions continue large, pasty-looking, and offen- sive, and are passed too frequently in the day, one drop of tincture of opium may be added to the DEODOKANTS. mixture, as there is usually in such oases too rapid peristaltic action of the intestines. In the case of either of these derangements "(vomiting or diarrhoea) it is of great importance to keep the body warm, and this is most effectually done by applying a broad flannel bandage to the abdo- men. The diet also should be temporarily modi- fled, reducing the quantity of farinaceou.'i matter tJiat is being taken, on account of the tendency to acid fermentation of food which is set up by such a condition of the alimentary canal. Looseness of the bowels during dentition has been looked upon by some writers as a natural method of relief to the system, and fears have been held out of grave troubles which might ensue if the looseness were too suddenly arrested. Such fears are, however, quite groundless, A catarrhal condition of the bowels should be cured as quickly as possible, especially daiiiag dentition, for it is at this time that the suscep- tibility to chills is so great, and the danger of severe choleraic diarrhoea being set up is there- fore correspondingly threatening. In some cases of teething, where the lungs as well as the bowels are the seat of catarrh and there is a risk of bronchitis, Trousseau recommends that the intestinal derangement shoidd not be suddenly put an end to : but even in these cases a dose of castor oil may be safely given to remove irritating matters from the canal, for, according to the writer's experience, any irritation of the bowels is apt rather to increase than to diminish pulmonary mischief. The favourite remedy for all disorders oc- curring at the time of dentition is lancing the gums, but the practice is one which ought not to be pursued indiscriminately. Unless the gum be actually swollen and tense, incising it has no object whatever, for to cut the top of the gum can have no influence in promoting the develop- ment of the tooth below. If, however, there be very much inflammation and swelling, and the child seem to be in pain, relief may be obtained by lancing, but in this case the object is merely to relieve tension. Excitement of the nervous system dependent upon the condition of the mouth can perhaps be allayed by the same means ; but in the case of convulsions more benefit is to be gained by the use of warm baths, cold appli- cations to the head, aud the gentle action of a mild aperient. Ecsxace' Smith. DEODOBANTS {de, from, and odorp, 1 cause to smell). Definition. — The term deodorant, although it has a more extended signification, is generally used to signify » substance that destroys offen- sive odours. Geneeal Pbinoipiobs. — Odorous bodies are essentially volatile, and those which are offensive frequently contain sulphur in some state of com- bination. Deodorants usually produce the effect for which they are used by causing a chemical change in bodies to which they are applied; but sometimes their action consists in absorbing and condensing odorous substances, and thus de- stroying or counteracting their volatjlitj^. Sub- stances which, like charcoal, possess this latter property may, however, indirectly produce chemical changes by bringing the odorous sttb- DEODOEANTS. Btancea into contact with oxygen in a condensed and active condition. Deodorants may be classed as volatile and non-volatile. 1. Volatile Deodorants. — These all consist of substances the action of -which is immediately and exclusively chemical. Being intended to act on bodies which are themselves volatils they admit (rf more generally useful application than those which are not volatile. EiniMBEATioN. — Chlorine and its lower oxides, Sulphurous Acid, Nitrous Acid and other oxides of nitrogen, Ozone and Peroxide of Hydrogen are the most important members of this class. Application. — In the selection and use _ of volatile deodorants, it is necessary to distinguish between bodies which possess the power of de- stroying or removing a noxious smell, and those which merely cover one smell by another. Car- bolic acid, for instance, which is a valuable dis- infectant, is of little use as a deodorant, al- though its powerful odour may render other weaker but more objectionable odours impercep- tible or indistinguisable. On the other hand, the so-called chloride of lime (chlorinated lime of the Pharmacopoeia), while it possesses a strong and characteristic smell itself, is capable of destroying other noxious odours, and is an excellent deodorant. The chemical action by which noxious odours are destroyed is principally one of oxidation, and therefore this class of deodorants are gene- rally oxidising agents. Ozone, or active oxygen, is the natural deodorant contained in the atmo- sphere, which no doubt largely contributes to the destruction of noxious vapours in the air. Volatile oils, which emanate from the flowers and other parts of plants, in contact with atmo- spheric oxygen produce peroxide of hydrogen, and this as an oxidising agent possesses deodor- ising as well as disinfecting properties. The moderate and judicious use of perfumes may thus produce a beneficial effect, although their undue employment, by hiding more than remov- ing what- is objectionable and may bo injurious to health, cannot be recommended. The prepa- ration called 'Sanitas' is principally a solution of peroxide of hydrogen. 2. ITon-Tolatile Deodorants.— Euumeba- TIOK. — Among this class of deodorants are in- cluded Charcoal, Earth, Lime, Oxide of Iron, Sul- phate of Iron, Chloride of Zinc, Nitrate of Lead, and Permanganate of Potash. Application. — Although very efficient when brought into contact with the class of odorous substances referred to as noxious gases, these deodorants are less generally useful than they would otherwise be on accoimt of their non- volatile character. Charcoal owes much of its eflcacy as a deodorant to the surface-attraction and power of condensation which it possesses, by virtue of which it brings noxious gases such as sulphuretted hydrogen into contact with oxygen in a condensed and active state, so that they are burnt up and resolved into innocuous compounds, or compounds less noxious than those from which tney are produced. Earth and oxide of iron, which, like charcoal, 'are used in the solid and dry, or nearly dry state, absorb and combine -with, or promote the combination of, noxious gases, pro- DEPLETION, 34S, ducing innocuous products. Lime may be used either dry or in the state of milk of lime. The other ajibstances named are used in the form of solution in water. Where large quantities of de- composing animal or vegetable matter are required to be deodorised, dry lime or solution of sulphate of iron (green vitriol) may be economically and advantageously used. T. Eedwood. DBPIIiATOBIES (depilis, without hair). Stnon. : Pailothron, Busmd. Definition. — Depilatories are agents used for destroying the hair by means of their chemical properties. Enomeeation and Action. — Depilatories usually consist of powders, of which the chief con- stituents are quicklime (three parts), and sul- phuret of sodium (one part), diluted with (four pails of) starch. The powder is mixed with water to the consistence of a thin paste, and laid oil the part to be operated on by means of an ivory paper-knife. In from five to fifteen mi- nutes the paste should be carefully scraped off, when the hair, shrivelled and burnt, will come with it. The skin must then be washed with fresh water, and dried, and anointed with cold cream. A strong solution of sulphuret of barium, made into a thin paste with starch, is a powerful depilatory. Erasmus Wilson. DEPLETIOIT (depleo, I empty). Synon. : Fr. depUtion. Definition. — By depletion is understood (o) the unloading, or rendering less full, of that which is over-burdened or over-full, for ex- ample, portions of the turgid vascular system — as the portal vessels ; or ■ (6) excessive eva- cuation causing exhaustion — as in choleraic or other severe diarrhoea. Uses.— Depletion, local or general, as a thera- peutic agent, may be practised in a variety of affections, such as cerebral' congestion, venous turgescenoe, engorgement of the portal, system, pulmonary congestion, renal ischeemia, or general plethora. Methods. — The agencies whereby depletion may be produced are blood-letting, general or local, purging, sweating, vomiting, and absti- nence from food and drink. 1. General Blood-letting. — There is no more powerful or prompt depleting agent than general blood-letting by venesection or arterio- tomy ; indeed, the chief indications for bleeding are to be found where it serves a depleting pur- pose — as in engorgement of the right heart and venous system, visceral congestion and arterial turgeseence. (See Blood, Abstraction of.) It is seldom, however, that abstraction of blood needs to be carried to such an extent as to exert a marked depleting effect on the whole system ; it is required, rather, for the relief of limited vaso-motor disturbances. 2. Local Bleeding. — Bleeding by means of leeches, scarifications, or cupping, may serve a very valuable depleting purpose in limited congestions, as in those of the pericardium, pleura, peritonseum, lungs, eyes, kidneys, tongue, uterus, and hsemorrhbidal vessels. 3. Purgation.— For general depleting ptir- poses free purging by means of hydragoguo 344 DEPLETION. Ciathartics is the most efficacious agent. In cere- bral, cardiac, and hepatic congestions, when it is required to give relief to turgid vessels -without abstracting blood, nothing depletes so readily, efficiently, and safely as watery purges. The best purgatives are : — Elaterium, jalap, senna, scam- inony, sulphate of magnesia or soda, tartrate of soda, bitartrate of potash, croton oil, and gamboge ; to which may be added, podophyUin, calomel, and antimony. Watery purges have the great advantage of depleting by removing sei> osity from the blood-vessels without the loss of red corpuscles. In cerebral congestion depletion by means of such purges is of cardinal service. In congestion of the intestinal tract arising from hepatic, cardiac, or pulmonary disease, a mer- curial followed by a saline purge is of great service. Antimony has been mentioned in the above list because of its usefulness in combina- tion with sulphate of magnesia and other saline purges. It should be remembered that it also acts as a depressant, and should only be used when such action is permissible. 4. Vomiting. — ^When used as an emetic, antimony has a powerfully depressant, as well Jis evacuant or depletory effect ; but depression vnd depletion are not synonymous. The low- ering effect of free purging is pronounced, and ordinarily, sufficient. Emetics may act as depletants by evacuating the contents of, or producing a flux from, the stomach ; but their depressan*; action is always to be borne in mind when used with this object. 5. Sweating. — This is a, less effectual mode of depletion. It may serve a good purpose, when freely induced, in lowering arterial tension, as in cases of renal disease, especially if there be pyrexia. Active exercise, the hot air (or Tur- kish) bath, the vapour bath, wet packing, jabor- andi, antimony, and Dover's powder are the usual modes of exciting diaphoresis. Diaphoretics are often aided by copious draughts of hot fluids. The evacuant action of sweating and purging may be advantageously combined when speedy depletion is desired. The combination is valuable in certain dropsies. 6. Abstinence. — General depletion may be produced by abstinence from food and drink, and is sometimes employed in the treatment of aneurism, and of strangulated hernia contain- ing omentum, the absorption of the fat of which is the object aimed at by starvation. Alfred Wiltshiee. DEPOSITS. — The term deposit had at one time a much wider extension in pathology than it has now. In accordance with the doctrine of morbid erases or dyscrasUs, it was customary to regard cancers and all new-growths, the products of tubercular and scrofulous diseases, as well as those of the specific fevers and ordinary inflam- mation — in fact almost every kind of morbid pro- duct in the body — as ' deposited' from the blond in consequence of some alteration in its composi- tion. In many of these cases the term deposit is still often used, even though an entirely different view maybe taken of the processes leading to these morbid changes. The name remains.though the idea has departed; and this is also true of other morbid products called deposits. The DEPOSITS. term secondarn deposits was formerly used for what are now called pysemic or secondary ab- scesses, from a belief that pus was removed from the original seat of disease, and deposited in dis- tant parts. The term atheromatous deposit is due to Eokitansky, who described thischange as dus to the deposition upon the arterial wall of material precipitated from the blood. In both these cases the term seems now misleading. Again, several processes which we now call degenerations oi infiltrations were formerly spoken of as deposits; for example, lardaceous, fatty, and pigmentary deposit ; and although these processes may now be better described by another name, it cannot be doubted that in some of them an extraneoun substance is actually deposited in the tissues. The term fhrinous deposits was also used for the masses now known as infarctions or blocks (as for example in the spleen or kidneys) where the appearance of a mass of extraneous material is produced by the degeneration as a msuS of tissue, mixed with products of haemorrhage; in- flammation, and exudation. In quite another sense the various substances precipitated from urine are spoken of as urinary deposits, with which we are not here concerned. When these exceptions are made, the present use of the word deposit is a limited one, but is appropriate in those cases where something dif- ferent £rom the elements of the tissue, and es- pecially if it be an inorganic material, is found 'in their substance, and when it may reasonably be supposed that this material has been brought to the tissues by the circulating fluid and there deposited. The term is clearly inappropriate when the foreign matter is formed by some chemical change in the substance of the tissue- elements, but between such cases and those just mentioned it is very diflicult to draw the line. We shall speak, in the sense just defined, of cal- careous, metallic, and pigmentary deposits. 1. Calcareous Deposits. — ^Ail calcification of the tissues of the body, whether normal or degene- rated, of inflammatory products, of new growths, or of any morbid products, appears to depend upon the deposition of lime-salts in the form of granules, this deposition taking place either within the substance of the elements, or more rarely in the intercellular substance, or, possibly, sometimes in the interstices of the tissue. Cal- careous deposit takes place towards the close of life in several parts of the body, as in the walls of arteries, in cartilages and tendons, in the valves of the heart, the crystalline lens- of the eye, and other parts ; though in most of these cases, if not in all, some other pathological change pre- cedes the deposition of lime. Still more frequently this change occurs in masses of dead or degene- rated materials, as, for instance, in organs which have partially or wholly lost their vitality, in. new-growths which have reached the stage of retrogressive change, in old blood-clots, or in products of bygone infiammation. A wasted eyeball always becomes partly calcified (some- times ossified) ; tumours, such as myoma and fibroma, are especially subject to calcification; venous clots which remain long undisturbed, as in the deep veins of the pelvis, undergo the same change, and become phlebolithes. Old inflam- matory products, as pus and lymph, seem to DEPOSITS. become necessarily calcified if they are not ab- sorbed ; so do especially the products of chronic degenerative inflammations which have become necrotic, as seen in scrofulous lymphatic glands, and in tubercular masses in the lungs. A similar explanation applies to calcareous deposit in the-waUs of arteries.-where the lime is generally deposited in new products which result from chronic arteritis or the atheromatous process, though lime may also be deposited in the muscu- lar walls independently of atheroma. Necrotic masses resulting from embolic infarction are fre- quently calcified. Parasites of all kinds, occur- ring in solid organs, are liable to become sur- rounded by a calcified wall : a change fijequently seen in hydatid cysts. From all this it appears that calcareous deposit rarely occurs in normal healthy tissues, but is common in such parts as are dead or of deficient vitality. Its deposition must be attri- buted to some chemical reaction between the tissues thus altered and the lime-salts in the blood, and it is possible that the presence of an excessive quantity of lime-salts in the blood sometimes favours the change, since deposition of lime in one part sometimes coincides with re- moval of it from another part. In senile decay the wasting of hones goes on simultaneously with the calcifying processes just mentioned, and in some rare cases rapid absorption of bone from special disease has appeared to be the determin- ing cause of its deposit elsewhere by a sort of DETERGENTS. 346 2, BEetallic Deposits. — Other minerals be- sides lime-salts are rarely found deposited in the tissues, although in cases of chronic metallic poisoning, compounds of lead, silver, and copper may be found thus deposited. Zinc.and mercury are less clearly traced, but probably follow the same law. The state of chemical combination in which the metals occur is not positively known, but appears to be some combination with albumen! 3. Pigmentary Deposits. — Pigmentation as a process is discussed in the article Degenera- tions, and has been shown to depend very fre- quentiy upon the occurrence of hsemorrhage and transformation of the extravasated blood. But pigment is deposited in many parts of the body, both normally and pathologically, quite inde- pendently of haemorrhage. Normally this is seen in the skin, the choroid coat of the eye, &c. : pathologically in the same situations, but in ex- cessive quantity; and also in abnormal situations, as on the mucous membrane of the mouth. The arraiUgement of the pigment is in every case the same, forming minute black granules in the pro- toplasm of the cells around the nucleus. Its deposition and removal are regulated by causes as yet very imperfectly known, but are probably in some way dependent upon the nervous system. The deposit of such substances as fat, larda- ceous material, colloid, &c., is not a simple pro- cess, but depends either upon chemical metamor- phosis of the cell, or on general pathological changes, which are dealt with in other parts of this work. J. I". Patnb. DERBYSHIBB NECK.— A synonym for goitre, which is thus called from the prevalence of the disease in that county. DERIVATIVES (derivo, I drain). Definition. — Medical appliances or remedies which lessen a morbid process, such as inflamma- tion, in one part of the body, by producing a flow of blood or lymph to another part. Entjmehation. — Derivatives include — Local bleeding. Cupping, Leeches, Blisters, Sinapisms, and Setons. Action. — The name 'derivative' was applied in ancient times under the belief that diseases were caused by morbid humours, which might be drawn away from the part which they were afiecting. It is now used chiefly to signify the diminution of blood in an inflamed part, by in- creased circulation in some other vascular dis- trict, either adjoining or remote from it. T. Laddeb BntJifTON. DEBMATAIiGIA (Se'pAto, the skin, and &Kyos, pain). — Fain and aching in the skin. See Neubaloia. DEBMATITIS (S^pua, the skin).— Inflam- mation of the skin, a term applicable to every variety of inflammation of the integument, but especially to an acute inflammation attended with exfoliation of the cuticle and copious desquamation, for example. Dermatitis Exfolia- tiva, the Pityriasis rubra of Devergie. DEBMATOLTSIS (Sep;"", the skin, and Kvtris, a, loosening). — Looseness or relaxation of the skin. See Cutis penduia and MoiLusctw. DESQUAMATIOW (de, from, and squama, a scale). — The process of separation or shedding of the epithelium of any surface. It is of moat importance in connection with the skin in scar- latina, where the epidermis usually desquamates extensively. DESQUAMATIVE HEPHEITIS. — A synonym for certain forms of Bright's Disease, applied on account of the shedding of the epi- thelium lining the tubules, which is character- istic of the disease. See Bbiqht's Disease. DETEBGENT3 {detergo, I cleanse). DEFiNiTiON.^Substauces which cleanse the skin. Enumebation. — The principal detergents are — Water, Soap, Alkalies, Ox-gall, Milk, Vinegar, Charcoal, Sand, Oatmeal, Sawdust, Pumice- stone, Oil, and Borax. Uses. — Detergents are used either to remove extraneous dirt adlierent to, or epidermal scales which may have accumulated upon the skin, and interfere with its function. The chief detergent is warm water, but its action is greatly aided by such substances as soap, alkalies, borax, or vinegar, which act chemically in the removal of dirt or epidermis ; or by such substances as oat- meal, sawdust, charcoal, pumice-stone, and sand, which act mechanically. Oil removes the resin- ous deposit left on the skin by plasters. Where the skin is tender, as in the case of the scalp, and where at the same time the detergent employed cannot very readily be removed, borax with elder- flower water may be found preferable to the more irritating soaps as a means of removing scurf. T. Latidee Beuntom, 346 DETERMINATION OF BLOOD. DETEBMIWATIOIT OP BLOOD.— In- creased flow of blood to a part or organ, synony- mous with active hypercsmia or active congestion. See CiEcmiATioN, Disorders of. DEVELOPMENT, Arrest of. — ^The causes of arrest of development are in most cases still very doubtful, and for the most im- portant theories and observations on the subject the reader is referred to the article on Mai- FOEMATioNS. Such arrests may take place at any stage in the development of the embiyo and of its organs ; but only the most fciportant of them, and the mode in which some typical examples are brought about, will be mentioned here. Vaeietibs. — Those which occur very early in foetal life are complex and, for the most part, incompatible with viability ; whilst those which occur later often affect only one organ or a set of organs, and in some cases form no barrier to a prolonged existence. Not only must the fcetus be considered, but also the placenta and membranes in whioli it is enclosed in mtero ; for diseases of these lead to many forms of monstro- sity, either by interference with the nutrition and respiration of the embryo, as in the case of many so-called ' true moles ' ; or the normal changes may be checked by adhesions between them and the fcetus. Persistence of the umbilical vesicle is excessively rare, but a patent vitelline duct is very common, and explains many of the diverticula in connection with the small intestines. A want of closure of the visceral laminse is the source of many deformities, from a simple fissure in the sternum, or a ventral hernia, to a complete an- terior cleft, with the thoracic and abdominal vis- cera lying bare out of the body-cavity. In other cases the skin and muscles only may cover the viscera, or the muscles may not be developed. The thorax is closed before the abdomen, so that ectopia of the abdominal is more common than of the thoracic viscera. The abdomen, however, is sometimes closed in, whilst the thorax remains open, and varying degrees of ectopia cordis result; but this is rarely complete. Epispadias and hy- pospadias to varying extents are further examples of imperfect fusion of the ventral laminae. These may or may not be attended with displacement or deficiency of the urinary and genital organs. Similarly from an incomplete fusion of the dorsal laminse the various forms of spina bifida occur, and these are generally accompanied with an ex- cess of fluid in the spinal canal, or hydrorachis. The arrests in the development of the cerebro- spinal centres and of the organs of special sense are very numerous. The whole brain may be want- ing, or the medulla oblongata developed and the remaining portions missing, or any given part Of it may be absent or quite rudimentary. From incomplete fusion of the bones of khe skull hernia cerebri or encephalocele occurs, and this is gene- rally comjjlicated with hydrocephalus, though the latter is frequently found as an independent and solitary affection. Coloboma and deflciency of the olfactory, optic, or auditory nerves are well- known examples of arrested development of the organs of special sense. The special malforma- tions of the heart and vascular system, the diges- tive, respiratory, and urino-genital systems, will be described under the various organs; but re- ference must here be made to congenital fissures DIABETES MELTJTCJS. leading into the pharynx (persistent branchial clefts), to the various fissures of the face and palate, to persistent cloacse, to the numerous forms of hermaphroditism, and to imperforate anus, as all coming under this head. Varying degrees of ill-developed extremities are common from a diminution of number in the fingers or toes, or their coalescence, to a complete absence of one or all the limbs. Finally, ducts, vessels and openings — such as the urachus, ductus arte-' riosns, umbilical vessels, and foramen ovale— which normally close soon after birth, may remain patent throughout life. Jomr Cuenow. DEVOITSHIBB COLIC— A synonym for lead colic, which has arisen from the frequency of lead-poisoning in that county, supposed to be due to the contamination of cider by lead. ' Set IiEAD, Poisoning by. DIABETES INSIPIDirS {Sii, through, jSo/'yiB, Iflow; and insipidus, tasteless). — Synon.; Polyuria ; Fr. Diabke insipide or non sucre ; Ger. Folymrie. AsynonymforPolyuria. SsePoLruHiA. DIABETES MELLITTJS (Siif, through, fiaiva, I fiow; and fie'\iTTo, a bee). — Synoh.; Glycosuria; Fr. Biabke; Ger. Hammckermhr. Definition. — The term Diabetes, meaning an excessive flow of something, has been applied to the pathological condition indicated by an ex- cessive flow of urine. It has, moreover; been almost wholly limited to the kind of malady characterised by the presence of a notable quan- tity of sugar in the urine — acdnditionmore strictly described by the term Diabetes Mellitus. Another condition is sometimes seen where no sugar is to be found in the ui'ine, which is, however, excessive in quantity. This is designated as Diabetes Insipidus, or better. Polyuria. Diabetes is n, malady more or less chrbnic, characterised by the persistent presence of a notable quantity of sugar in the urine, which is in most cases markedly abundant. It is accompanied by thirst, hunger, and bodily wasting. If iin- relieved it invariably tends to death. The ordi- nary form of Diabetes is thus to be distinguished from certain other conditions, where, for instance, a small or hardly perceptible trace of sugar may be detected in the urine ; or where, yet again, considerable quantities of that substance may be detected occasionally, and for a short time only. To this abnormal condition the term Glycohum (yXmis, sweet, and olpor, urine), which is often also employed to describe artificial diabetes, best applies. Geneeai. Considerations. — Three important facts lie at the bottom of our knowledge of tho pathology of Diabetes.' These are : — I. That grape sugar is found in the healthy human body. II. That glycogen, a substance closely allied in chemical composition to grape sugar, is also found in the healthy human body. in. That both of these may be formed in the healthy human body. Beyond these, certain other fairly definite pro- positions may be made. ' The discussion at length ol the subject GlyoogcnfBltj which formed part of the orlginiil article, has for vant ox space been here omitted.— ED. DIABETES MELLITUS. 847 1. Glycogen is found most abundantly in the liver, insomucli that, with due precautions, it can always be detected there : after a certain time sugar takes the place of glycogen, but the exact mode and time of this conversion are not known. 2. Nevertheless, it is feiily certain that the sugar called glucose can always be detected in the liver ; still more certain that it is to be found in the blood ; but 3. This sugar never appears in any notable quantity during a state of health in the urine. 4. As sugar is not to be found in any appreci- able quantity in any other of the excretions, it follows : 5. That this sugar must disappear in the body. 6. It is commonly asserted, and, upon the whole, believed, that sugar is Jess plentiful in venous than in artenal blood, 7. From this, if true, it follows that sugar must be used up in the course of the circula- tion. 8. Where the combiistion, or oxidation, occurs is not quite clear. 9. But it is plain that, from a fault in either direction, sugar may become over-abundant in the blood, namely : — a. My over-j>rodiiction, or b. Sy diminished cotiswnption. 10. The over-production and the diminished consumption of sugar in the body may depend on various causes. The most notable of these are (a) an increased ingestion of saccharine ma- , terial into the stomach and bowels, without a corresponding destruction ; and (i) such an alte- ration of nerve-influence as will completely modify the relative proportions of the sugar produced and the sugar destroyed, 11. With an excess of sugar in the blood, only one easy road of egress from the body is available, that is, by way of the kidneys ; but this is not a sufficient outlet when there is great superabun-; dance in the blood. Sugar may then be found in almost every one of the secretions or excretions, 12. With this unnatural discharge of sugar there is usually a corresponding discharge of urine, but not always. ; , 13. Thus there may be no greatly increased flow of urine, yet the urine may be rich in sugar. 14. And yet, again, there may be a copious flow of urine without any sugar, as in Polyuria. 16. Hence the over-production or the dimin- ished consumption of sugar in the system has no necessary connection with increased flow of urine. 16, Both the abnormal action of the liver and that of the kidneys seem in the main to depend on similar but not identical causes. 17, Both seem to be under the control of the sympathetic, but the special fibres are not the same as regards the two organs. (a) In the case of the liver the fibres seem to originate in the medulla oblongata, to descend in the spinal cord to the lower cervical or upper dorsal vertebrae, thence to leave the cord to join the gangliajed sympathetic, and so ultimately to reach the liver. (J) In the case of the kidneys the active fibres proceed further down the spinal cord, but are tiltimately connected with the great abdpminal plexus, for such it may well be called, whence the fibres proceed to the kidneys. JEtiologt. — The classification of cases of dia- betes apoording to causation is in very many oases practically impossible. As to the circumstances that call the morbid processes into play, we know very little. It is certain, however, that the disease is much more frequent among men than among women, and among the middle-aged than among the very young or the very old. The disease is very much more fatal in young adults than in those over, say, forty-five. That the disease is more rife in certain districts than in others may probably be best explained by its undoubted tendency to heredity. This heredity, as in many other mala- dies, is peculiar ; the diabetic tendency in one branch of a family being represented in another branch by various nervous disorders, especially epilepsy and imbecility. Of the so-called exoitvag causes there are two of the first rank, namely, injury, or disease of the brain ; and mental excitement, or, perhaps still more, worry. Tumours and other local brain- mischiefs sometimes give rise to a fatal diabetes. Certain mental emotions, at once powerful and pro- longed, which maybe epitomised in the single word strain, apparently act as exciting causes of dia- betes, such as continuous anxiety, long-lasting grief, or excitement followed by reaction. Cer- tain errors of diet — such as excessive use of hydrocarbons, especially sugar — or other inter- ference with the laws of health, may originate a fatal diabetes, especially in those who have any heredittuy tendency to the disease. It is possible that the frequency of the malady among the Jews (as noted by Seegen) may bo accounted for on dietetic grounds. Ahatomic^ Chabaoteks. — Many pathological conditions have been recorded as occurring in tliose who had been the subjects of diabetes, but we know little of its real pathology. In many cases nothing which can be directly connected with the diabetes has been found post mortem. Latterly attention has been mainly directed to the investigation of certain parts of the nervous system and of the liver itself. Perhaps the most reliable data for the ordinary anatomical ap- pearances are to be found in Seegen's analysis of Kokitansky's experience, embracing 30 ne- cropsies. Connected with the brain and spinal card various lesions have been found, such as tumours of different kinds pressing on the medulla, and softening, with or without the marks of extrava- eated blood. In some cases extravasation has been the only morbid change discovered. In two oases under the writer's care there were ex- travasations of blood in the spinal canal in the cervical and upper dorsal regions, and the same was observed in another case under the care of' a colleague. In one of these there was very marked softening of the cord in the regions named. In these three cases death topk place suddenly, Dr, Dickinson's theory of the origin of diabetes in lesions of the nervous system, re- presented by enlarged perivascular spaces, the sites of existent or pre-existent extravasations of blood with destruction of the surrounding nerve tissue, is hardly tenable. The exploration S48 DIABETES MELLITUS. of tho sympathetic system has not been more satisfactoiy. Eokitansky found (in 15 out of 30 cases) that the liver was enlarged, hypersemie and hard, of a dark-brown colour, with its acini imperfectly defined. The Bame conditions -were present in the cases examined by the writer. When the disease has lasted a long time, the liver may be smaller than natural. The same would appear to hold good -with regard to the cells themselves. Early in the disease, lie cells, especially in tho outer portions of the acini, are large, plump, and rounded, instead of angular, with large and dis- tinct nuclei. They tend to assume a wine-red colour ■with solution of iodine, from the presence of unchanged glycogen. There are also sometimes found signs of active cell-growth at this early stage. Later the cells seem smaller, and as if undergoing pigmentary degeneratipn. The condition of the pancreas in diabetes is highly interesting. In 13 out of Eokitansky's 30 cases, it was strikingly small, hard, and blood- less ; and in many cases it has been found so shrunken and altered as to be hardly recognis- able save by its connections. Such was the case in one instance the writer has seen, and in all his other cases the pancreas has been abnormal, usually contracted here and there, hard and knotty. In one case, however, the organ was enlarged and more succulent than usual, pro- bably the first stage of the mischief. The oc- currence of so important pancreatic changes in about one-half the cases of diabetes would seem to indicate more than a casual connection with the disease. What this connection really is re- mains unascertained. Klebs has associated the changes with disease of the coeliac plexus. One result from the pancreatic mischief is inability to digest fat. This was seen in one of the cases referred to above. The kidneys Bokitansky found diseased in 20 instances, but the changes were not uniform. Usually they presented the ordinary indications of hyperaemia, being enlarged, dark red, and full of blood. Occasionally there were signs of more extensive mischief, the substance of the kidney as well as its vessels and epithelium being in- volved, and the organharder than natural. Often fatty changes occur. In one case of the writer's amyloid changes had begun in the Malpighian bodies. The lungs are frequently diseased : in only 7 of his cases did Bokitansky find them normal ; Dickinson only twice out of 27 instances. The changes included all stages, from acute or chronic pneumonia, to the formation of numerous cavities, or even to gangrene. In one of the writer's cases the whole of theupper lobe of one lung was con- verted into a htge cavity filled with solid and semi-fluid detritus, having no gangrenous odour. There had been no expectoration, and no haemorrhage, though vessels were exposed. The stomach and intestinal canal present little beyond the ordinary signs of recurrent or chronic catarrh — thickening, mammillation, and slaty pigmentation; erosions and ulcerations may, however, occur. SrMPTOMS. — The following sketch comprehends the more characteristic clininal feahires of dia- betes ; but there are often important variations in individual eases, though a certain number of features are common to all :— The patient, most likely a ' male between twenty and forty-five, when he comes before the physician has in all probability been sufFering from the disease for some time ; for it usually comes on insidiously. He may say that he has been in failing health for a varying period ; that he has been very thirsty, and has passed much water, having to get up repeatedly for this purpose during the night. His appetite has been more than hearty; but his food seems to do him no good, for he has been constantly growing thinner, and he feels weak and ill. On closer examination it is found that he is daily passing as much perhaps as eight, ten, or more pints of urine, light in colour and of a peculiar sweetish odour, of a high specific gravity, perhaps 1040, and contain- ing an abundance of sug£ir. The skin is dry and harsh; the tongue red and glazed or slightly furred ; the mouth dry and clammy ; the lips, teeth, and gums are covered with scanty, sticky mucus ; the breath is often sweetish, or it may be unpleasant from the state of the mouth ; the bowels are confined ; and the countenance wears an expression of weariness and fatigue. From this point the malady may progress in one or other of two directions. Under judieious management the symptoms may ameliorate. Often the first indication of improvement is a copious perspiration ; the thirst diminishes ; less urine is passed ; the appetite is not so ravenous ; the sugar decreases in quantity ; and with it the specific gravity is lessened. Emaciation ceases, and the patient begins to regain weight. This auspicious commencement may, with time and care, end in a more or less complete return to health. Unfortunately there is another side to the picture, for notwithstanding all our efibrls the patient often goes from bad to worse. We fail to reduce the quantity of sugar beyond a certain point. The appetite gets more and more voracious, especially for starchy articles of food, for which the patient wUl sometimes lie, steal, do anything, and yet there is often no feeling of satiety. Sometimes the appetite fails, and then emaciation goes on still more rapidly. All sexual power and feeling have long ago been lost, the testes sometimes undergoing almost complete atrophy. The harsh, dry, and itchy skin becomes the seat of boils, or even of carbuncles. Often the sight is injured by cloudi- ness of the refractive media, especially of the lens, or by other and more anomalous changes. All this time the temperature is low, perhaps sub-normal ; but towards the later stages of the inalady it often rises. Such a rise indicates the accession of a formidable complication which might almost be said to be the natural ter- mination of diabetes. This superadded mis- chief is a peculiar insidious kind of pneumonia, resembling acute pneumonic phthisis, and giving rise to local signs resembling those characteristic of that malady. The progress of this lung^mis- chief is rapid, the fever increases, and often there is irrepressible diarrhcea, sometimes of fatty- looking matter. As the end approaches, the sugar usually disappears from the urine, which may become albuminous and scanty. There may even be some oedema of tho extremities. The end DIABETES MELLITUS. 349 ofton comes swiftly, and without warning, by acute pneumonia, or by what, for want of a better name, we call diabetic coma, or more slowly by gradual exhaustion. After tha onset of pul- monary symptoms it is never very long delayed. Such may be said to be the ordinary course of a well-marked case of diabetes. _ There are cases slighter, where the history is different ; but in both sets of cases there are certain symptoms, which demand further consideration than has been given them above. 2Se Urine.— The characteristic of the urine in diabetes is the presence in it of sugar in notable quantity, though this varies greatly in different cases. In the earliest and slightest forms of diabetes, small quantities of sugar may he passed now and again, as after a meal or the consumption of an unusual quantity of starchy or saccharine food ; but the sugarmay completely dis- appear in the interval, or may do so finally by the use of an animal diet. The sugar thus excreted is glyoose of the kind called dextrose, from turning polarised light to the right, is readily soluble in water and alcohol, and easily ferments. When dia- betic urine is allowed to stand in a warm place, fer- mentation soon sets in, gas being disengaged, and yeast deposited at tne bottom of the vessel. The proportion of sugar to urine is usually from 8 to 12 per cent., but varies ; the total quantity passed amounting to 20 or 25 ounces, or even more. Its presence in such proportion cauises an increased specific gravity, though this is not invariably the ease, inasmuch as it may vary from 1,008 to 1,060 or 1,070. Along with the presence of sugar, we almost invariably find an increase in the quantity of the urine. But neither is this an invariable feature of diabetes, for sugar may exist with a normal quantity of urine, constituting the so-called Diabetes decipiem. !But in most cases, there is a marked increase, the quantity passed amounting to 8, 10, or 15 pints daily; and even the highest of these rates has been greatly exceeded. With an excessive amount of urine, its colour becomes lighter; sometimes it has a faint greenish tint, aud when passed is quite clear. On standing there is no ordinary sedi- ment, though, as already said, sporules of yeast may be deposited after a time. There is on the whole an excess — sometimes a large excess — of urea, and if the quantity of urine passed be small, urates or other urinary ingredients, as sulphates and phosphates, may appear. Very great incon- venience may arise in diabetic females, or even in males, by the arrest of saccharine urine about the external genitals, producing a raw or eoze- matous condition of the inside of the thighs and groins. The urine being also almost in- variably acid, is highly irritating to the raw and swollen parts. Enuresis is common, especially at night, and among diabetic children. Albumen makes its appearance sometimes in the progress of, or in the later stages of the disease. The Digestive Organs. — As the correlative of the unusual flow of urine we have also, as a marked and early symptom of diabetes, extreme thirst, a thirst too which cannot be satisfied, for apparently the more the patient drinks the greater is the thirst. This sensation is in some part due to the dry and clammy condition of the mouth, which it is difficult to relieve. Hunger, or even a voracious desire for food, is usually a prominent feature in diabetes, but is not invariably present, and in the later stages there. may be complete loss of appetite, amount- ing to a loathing, especially for a restricted diet. It is often impossible to satisfy the intense crav- ing for food, and should satiety be attained the sensation lasts but for a little time. The mouth is usually dry and parched, the saliva being scanty and tenacious. Often particles of food are re- tained about the teeth, and there putrefy, giving rise to unpleasant odours. The buccal fluid is almost always acid instead of alkaline, probably from the formation of lactic acid. The tongue is rarely perfectly natural. Seegen describes it as usually thickened and increased in volume, with fissures and glazed blood-red islands on its surface, which, however, may present a general coating. The teeth often fall out without pain from the retraction of the gums, and are sin- gularly liable to caries. Digestion is usually good, except during catarrhof the stomach, which is a rather frequent condition. Constipation is the rule in diabetes, often to a troublesome extent. This arises partly from the deficiency of water in the bowel ; partly also from the small quantity of fsecal residua from an exclusively meat diet. Diarrhoea, on the other hand, is not uncommon, and rapidly deteriorates the patient's strength. Generdl Symptoms. — Emaciation is an early and marked symptom of diabetes, but not in- variably so, for diabetes often occurs and persists in stout persons, without removing the obesity. These are cases of the more tractable kind, the patients being usually somewhat advanced in life. Their complete cure is seldom effected, but they do not seem to suffer greatly from the malady. Though the emaciation is in great part due to the removal of fat, and in part to the abstraction of water from the tissues, there seems to be also an actual waste of muscular substance, especially in the advanced stages of the disease. With this emaciation are asso- ciated weakness, weariness, and disinclination to exertion. These are often among the earliest symptoms of the disease, often occurring long before wasting is noticed, and increasing markedly towards the close of the malady. From various causes, one being, doubtless, weak- ening of the heart, oedema of the lower extre- mities may occur, with or without albuminuria. Gangrene of the extremities, of the senile kind, has been observed. Eespiratory apparatus. — ^With regard to the respiratory organs, a peculiar apple- or hay-like odour of the breath is sometimes observed, pro- bably arising from the production of acetone mixed with alcohol. But the most serious pul- monary symptoms are those of phthisis, resulting from a more or less chronic pneumonia. This mischief is usually indicated by a nightly rise in the temperature, but otherwise may remain for a time almost latent. It is most com- mon in ^e young, and towards the end of the disease.. The expectorated matters may contain sugar. Gangrene of the lung, or a form of necro- sis of the lung-tissues, has been noticed. With this form of gangrene the sputum may be odour- less. SMn. — The skin is usually dry and scurfy, often 350 DIABETES MELLITUS. extremely itchy; wounds inflicted ty scratching heal with difficulty. Copious saccharine sweat is observed in a certain number of instances. There is a marked tendency to the formation of boils and carbuncles. Boils often occur early in the disease, and may give the clue tc the exist- ence of diabetes. Carbuncles occurring l&te in the disease may be tiie immediate cause of death. UTervous System and Special Senses. — The sight is often aifeoted in diabetes, most frequently by the formation of diabetic cataract. Operations in such cases do badly till the disease is cured, and are seldom tried, for the cataract occurs late in the disease, and advances rapidly. A form of retinitis not unlike that of albuminuria is sometimes found. Other forms of imperfect vision of uncertain origin occur in diabetes. They go by the general term of diabetic amblyopia. Along with the physical, the mental powers fail, and all moral sentiments become blunted, which, to the friends of the patient, is not the least distressing feature in the malady. Genital organs. — Early in the history cf the disease, all sexual appetite disappears, and sexual power soon fails in the male — but with improve- ment this may return. In the advanced stages amenorrhoea is not unusual amongst females. Complications. — Several of the symptoms just described are regarded by some authorities as complications of diabetes rather than as belonging essentially to the disease. Such are especially diabetic cataract and amblyopia, boils and carbuncles, and the chronic pneumonia or phthisis in which diabetes so frequently ends. Gangrene of the extremities has also been occa- sionally observed. Amongst the intercurrent . diseases that are specially to be watched for and seriously regarded, one of the most important is albuminuria, the appearance of which may en- courage a false prognosis, from the fall in specific gravity of the urine that attends it. Diagnosis. — The diagnosis of Diabetes de- pends on the discovery of sugar, in notable quantity, in the urine of the patient. But before the investigation for sugar is undertaken, there have usually been observed by the patient some of the early indications of diabetes, of which the following are the most frequent, though no one definite symptom invariably heralds thedisease: — 1 . dryness of the mouth and thirst ; 2. bodily weakness and gradual emaciation ; 3. dryness of skin, with itching and a tendency to succes- sive crops of boils ; 4. urination in increased quan- tity, the urine being of agreenish yellow tint, with the odour described ; 5. defects of vision. Occasion- ally the attention of the patient is drawn to the state of his urine by the attraction it presents to ants, flies, and other insects ; or by the formation of white spots of sugar on his dross or boots left by the urine on evaporation. We must not forget that in true diabetes we find sugar in notable quantity. There are often present in the urine other reducing agents (such as uric acid and colouring i||itters), so that the amount of sugar detected ' must be such as to admit of no doubt whatever. Again, the presence of the sugar must be persistent, hence a, single examination will not suffice for diagnosis unless sugar be found in large quantity. It may so happen that the patient when seen is not passing sugar, from the influence of restricted diet, or from some other cause, such as pneu- monia or other feverish condition. It is then best to examine the urine passed an hour or two after a meal, or even to permit the use of starchy food for a day or two, so that the constitutional proclivities of the patient may be the better as- certained. To determine the existence of sugar is not enough ; it is always necessary to deter- mine the quantity passed, so as to obtain a diio to the intensity of the disease, and to judge of the effects of treatment. Qualitative testing for sugar. — 1. Specific gravity. — This almost invariably exceeds that of the healthy secretion. If a large quantity of urine is being passed daily, the specific gravity of which is upwards of 1030, we have good primA fade grounds for concluding that sugar is present. But as urinometers are often inaccu- rate, this criterion is of doubtful value. 2. Formation of torvla. — When saccharine urine is allowed to stand for a time in a warm place, sooner or later fermentation is set up, with the formation of yeast-fungus (Torula cerevisue). The detection of the fungus by means of the mjcroscope has Been proposed as a test of the saccharinity of the urine. Such a test is of little use, for the spores of the ordinary mildew fungus (Pemcilli-um glaiicum) can hardly be distinguished from those of the yeast-fungus, and penieillium will grow on any decomposing organic matter. 3. Fermentation. — The fermentation of saccha- rine urine may be greatly accelerated by adding to it some fragments of dry German yeast, and placing it in a moderately warm place. The production of alcohol and carbonic acid which results is a certain test of the presence of sugar in the urine. This procedure, however, takes some time and is not very delicate, requiring about five parts of sugar in a thousand, or two and a half grains to the ounce, to give any satis- factory result. It is best managed as follows. Take a large test-tube, or ordinary medicine-bottle, place in it some fragments of yeast, and fill up with urine. Fit a cork with a hole bored through it with a bent glass tube, one end of which will reach nearly to the bottom of the bottle that is to contain the urine. Fix the cork firmly in the mouth of the bottle, so that the bent end of the tube shall turn away from its side, and over a wine-glass or similar collector. When fermenta tion begins, the carbonic acid coUeeting in the top of the bottle will press downwards on the fluid, which will thus be forced up through the bent tube, and fall into the wine-glass or other receiver. An important and valuable modifica- tion of this test will be noted hereafter. 4. Moore's test or Heller's test. — When saccha- rine urine is boiled with liquor potasssE the sugar is decomposed, and a compound is formed, giving its colour, black or brown; to the fluid; A con- venient test-tube is flUed one-third full with the urine, and an equal quantity of liquor potassse is added. The two should then be well mixed by shaking, and the heat of a spirit lamp applied to the upper portion of the mixed fluids. If sugar be present this portion will gradually darken, the tint assumed varying in depth according to the quantity of sugar present. This test is very convenient, but it is liable to several objections, notatly these :— (a) Xt is far from delicate, re- quiring as much as three parts in a thousand, or a grain and a half of sugar to the ounce, to afford any satisfactory indication, (i) It is practically useless for quantitative purposes, though the plan has heen tried of comparing the colour produced with the colours of solutions containing kno-wn quantities of sugar, as is done in the Nessler process for substances producing ammonia and its allies, (o) It is liable to two notable fallacies. (1) High-coloured urine is always darkened in tint, sometimes blackened, by boiling with liquor potassse. (2) Liquor potassiE very often contains lead, which is liable to be converted into black sulphide, when boiled with caustic potass, if albumen or any organic matter be present in the urine. The former of these risks cannot well be obviated. The latter may, by first testing the purity of the liquor potass*, and keeping it in green glass instead of white glass bottles. 6. Tioettger'a test consists in the action of sugar as a reducing agent on bismuth. A small quantity of urine having been poured into a test-tube, an equal bulk of a solution of car- bonate of soda (one part of crystallised carbonate of soda to three of water) is to be added, and a small quantity of the ordinary basic nitrate of bismuth introduced. The whole is to be heated, when the appearance of a grey or black colour will indicate the reduction of the bismuth, and the presence of sugar. Albumen in the urine gives rise to a similar fallacy as in the last test, by the formation of a black sulphide of bismuth. Other metals, as silver, chromium, and tin, may be reduced in like manner, but by far the most convenient practically is copper, which is now almost universally employed for this purpose, as in 6. li-pmmer's test. — The usual mode of pro- cedure is to take a drachm or two of urine in a test-tube, to add to it a few drops of solution of sulphate of copper, then to add liquor potaasffi in excess, and to boil. When sugar is present a red or orange-coloured deposit of suboxide of copper should be thrown down. To this simple mode of testing there are several objections. If excess of copper be used some of the bluehydrated oxide of copper may remain unchanged, and so give rise to confusion. If too much liquor potassse be used it may blacken the sugar. Hence it is better to add the liquor potassse first, then to add the copper solution drop by drop. A bluish-white precipitate forms, which dissolves on shaking. In this way a splendid blue fluid is produced. "When the precipitate ceases to dissolve, neither reagent can be in excess, and heat may be applied. This solution of the blue precipitate is due to the presence of sugar, but many other organic substances have the same effect. Among the substances which possess this property, yet do not reduce the copper by boiling, is tartaric acid, and advantage of this has been taken for the production of a test-fluid not open to the above objections. The employ- ment of this is known as 7 FelMnff's test or method. — This testing fluid may be procured ready-made, but the following is the formula for it, as slightly modified by Pavy, and fitted for daily use : — ^Five grains of DIABETES MELLITUS. 3S1 sulphate of copper, ten grains of neutral tartrate of potash, and two drachms of liquor potassse. A more exact formula will be given farther on. The fluid thus formed is of an intense blue colour, clear and bright. When the test-fluid is to be used, a small quantity of it should first be raised to the boiling point, because by prolonged keeping the tartaric acid undergoes change, a substance being formed from it which is capable of reducing copper, and might give rise to confusion. But if on boiling the test-fluid no copper is thrown down, the suspected urine should be added drop by drop, the mixed fluid being at the boil- ing point. If sugar be present in quantity it wUl throw down the copper in the form of a red or orange precipitate. The quantity of urine added must never exceed the bulk of the teat- fluid, and the upper portion of the fluid should be heated, so as to contrast with the lower portion. Should suboxide of copper be thrown down when the test-fluid is boiled, the fluid must be filtered before adding the suspected urine, or, still better, a new fluid be prepared. To obviate as far as possible such inconveniences, the cuprio and alkaline fluids should be kept in separate bottles until about to be used. When the quantity of sugar in the urine is very small, as may occur in ordinary diabetes after long fasting or the use of a rigidly restricted diet, or during an access of fever, still more minute precautions must be taken. When, from any cause, the sugar present is less than three parts in a thousand, various anomalies may occur in the reaction. . It is in such cases that the reducing power of uric acid and the urinary colouring matters assumes importance. With this small quantity of sugar the copper deposit is never red, but yellow ; and we may have appa- rently any intermediate shade of colour from the deep blue of the copper solution through all varieties of green to yellow, with or without deposit after standing. Again, if the urine con- tains much phosphates, boUing with the alkaline solution may throw them down, and if at the same time the normal urinary constituents reduce some of the copper, the precipitate may roughly resemble a deposit of copper produced by sugar. It may thus be necessary to decolorise the urine, which may be done by passing it repeatedly through a filter of animal charcoal. Another difficulty is the presence of albumen in the urine, which renders the test nugatory. Accordingly in all cases, before applying any kind of test, the albumen must be removed by boiling and filtration. Quantitative Testing for Sugar. 1 . Fehlincfs volumetric method. — This method, now in common use, is founded on the fact that the proportion in which sugar reduces copper is constant. One equivalent of grape sugar decomposes exactly ten of sulphate of copper, or 180 parts by weight of grape sugar decompose 1246 8 parts by weight of sulphate of copper. This being borne in mind, and a copper solution of known strength being used, it is easy to determine the quantity of Bu^r in any given specimen of urine. The quantities may be calculated according to the metric system or by grains and minims. If we adopt the metric system, our fluid will coiiefet of the following ingredients : — 852 Sulphate of Copper (crystals) 40 grammes. Tartrate of Potass (neutral) 160 grammes. Liquor Sodffi (Sp. gr. 1-12) 750 grammes. Water to 1154-5 cubic centimetres. These should be carefully mixed, or, what is better, the copper aad alkaline solutions made separately, so that five cubic centimetres of each, or ten of the mixed fluids, will exactly decompose ■05 gramme or 50 milligrammes of sugar. According to the English system of measure- ment. Dr. Pavy's solution is the most convenient. It consists of sulphate of copper, 320 grains, dis- solTcd in ten ounces of distilled water ; and tar- trate of potash (neutral), 640 grains, with caustic potash 1280 grains, also dissolved in ten ounces of distilled water. These fluids may be kept separately or mixed. In mixing, the copper should be added to the alkaline solution, not vice versd, to prevent the formation of any precipi- tate. One hundred minims of this mixed fluid are decomposed by half a grain of sugar. Only a minim measure and a porcelain capsule or other vessel, which will stand heat, are required for Pavy's solution in the procedure which is as follows : — Most specimens of diabetic urine, con- taining too much sugar for accurate testing, first require dilution with water, and the most convenient degree of dilution is when one-tenth of the fluid is urine. Next put ten cubic centimetres of the metric copper solution, or one hundred minims of Pavy's solution, carefully measured, in a small porcelain capsule. The fluid being deep blue is better for dilution, so as to diminish the intensity of tint. Of course this does not alter the quantity of copper present in it. The porcelain capsule with its contents is to be placed on an iron retort -stand, at such a level that the flame of a spirit lamp will easily play on the capsule. Meanwhile a pipette, graduated from above downwards, eithra in minims or cubic centimetres, is filled up exactly to the in the graduated scale with the diluted iirine. When the solution of copper is boiling, the urine is added to it from the pipette, drop by drop, stirring carefully the while, until signs are shown of a decoloration of the cupric solution. The moment all the copper has been thrown down as suboxide, and all shade of blue or green has disappeared, the addition of the diluted urine is stopped, and the quantity already used read ofFon the graduated pipette. To ascertain the quantity of sugar in the urine is now a simple calculation. We know how much urine has been employed in reducing the 10 cubic centimetres, or 100 minims of the cupric fluid, but these measures represent exactly 50 milligrammes and half a grain of sugar respectively. The quantity contained in the diluted urine being hence deduced, multiply this by ten, to get the quantity contained in the urme as passed. Next multiply by the total quantity of urine passed in twenty-four hours, to ascertain the full amount of sugar passed in this period. In all such analyses the sample examined should be taken from the mixed urine passed during the whole twenty-four hours. That passed at night is the richest, that passed in the morning poorest in sugar. 2. Roberts' fermentation method. — We have already notdoed the fermentation method for demonstrating the existence of sugar in urine. DIABETES MELLITUS. Dr. William Eoberts, of Manchester, has alga devised from it a highly accurate quantitative process. It is as follows : — Put about four ounces of the suspected urine into a clean eight- or twelve-ounce glass bottle. Introduce a piece of dry German yeast, about the size of the point of the forefinger, but divided into small pieces. Cork the bottle with a grooved cork to allow the escape of gas. Fill a com- panion bottle quite fvll with .the urine. Cork quite tightly, and set both aside for twenty-four hours in a warm place — the mantelpiece will do. By the end of that time fermentation will pro- bably have ceased, and the yeast fallen to the bottom ; but if not, being suspended it will not affect the specific gravity of the fiuid. The specific gravity of the two specimens must now be carefully taken with an accurate urinometer, that of the unfermented bottle being taken as the standard. The fermented urine will have lost weight from two causes. 1st, the sugar which gave the increased specific gravity has been destroyed ; and, 2nd, in its place have been formed alcohol, which is lighter than water, and carbonic acid, which has escaped. Every degree of specific (fravity thus lost represents a grainof sugar in the ounce of urine. Thus, if there is a loss of twenty-five degrees of specific gravity, the urine would contain twenty-five grains of sugar in each ounce. Multiply this by the total number of ounces passed, to get the amount of sugar discharged per diem. This plan is especially useful for noting the quantity of sugar passed day by day, and can be easily undertaken by the patient or his friends. 3. Estimation by the polariscope. — A plan of estimating sugar employed a good deal abroad, depends on the power of diabetic sugar to turn the plane of polarisation to the right. The de- gree of rotation is in proportion to the quantity of sugar contained in the urine. The apparatus used commonly goes by the name of the Ventske- Soleil apparatus, from its inventors. It is best adapted for light-coloured urines. If the urine be deep in colour it requires to be diluted. 4. Estimation by specific gravity. — The rudest mode of estimating sugar is by the specific gravity of the urine. Since the methods described above were introduced, there is no excuse for its em- ployment save as a preliminary test, which may suggest the idea of sugar in the urine. To facilitate its use tables were drawn out, but the great increase of urea often found in dia- betes renders the test of but little accuracy. Pkosnosis, Couese, and Termination.— The prognosis of confirmed diabetes is ever unfavonr- able. Amelioration is common, but a perfect cure, save in exceptional cases, is rare. Diabetes coming on suddenly and from special causes, suCh as injury to the head, is more likely to do well than when more gradually developed. The younger the patient, the more sugar passed, the greatei the emaciation and debility, the worse the prog- nosis. Diabetes persistent with pure flesh diet is worse than if persistent only with a free starchy or saccharine diet. Loss of appetite and of digestive power, as indicated by the condition of the faeces, is of evil omen. When albumen appears in the urine in the course of diabetes the specific gravity of the fluid diminishes, often DIABETES MELLITUS. 353 giving rise to a false impression to the effect that, as the specific gravity has decreased, the diabetic state must be improved. The only true test of recovery is the power of consuming ordinary mixed foodwitii impunity; but Seegen says that out of two hundred cases he had never seen this re- sult. But by rigid or limited dieting, the patient may live, and even enjoy life, for many years. Heredity, directly op collaterally, adds to the blackness of the out-look. Cases resulting from injury to the brain or other parts of the nervous system are often the most hopeful with which we have to deal, though by no means always so. The course of diabetes is on the whole chronic. Most frequently it develops gradually, though in some cases suddenly, and it generally lasts from six months to three or four years. In stout elderly persons it may exist much longer, especially with good digestion and alimited dietary. On the other hand. Dr. Roberts records a case which proved fatal, after a well-marked onset, in eight days — the shortest period known to the writer. Another case was fatal in three weeks, the patient being three years old. Some cases are recorded of death at still earlier periods, but these were most probably cases of long duration in an unnoticed shape suddenly developed into an aggravated form. A fatal termination of diabetes may be brought about, as already indicated, in various ways. One is by diabetic coma, not unlike the first stages of nreemia. This may prove eud- denly fatal, and has been described as due to fat embolism, or to acetone in the system. In the advanced stages of diabetes, the strength being very low, comparatively slight causes may produce fatal effects. . Theatment. — Though we areignorantonmany j paints as regards diabetes, yet when we come to its treatment, we have these undoubted facts — that sugar cannot be formed out of nothing ; and that the series of substances out of which it may be formed is limited. And though we cannot absolutely succeed in feeding the patient on substances wliich will not yield sugar, we can supply a nourishing diet furnishing sugar-form- ing materials in the scantiest proportion— an end best attained by a pare meat diet, ^ut besides dietetic measures, other, though subsidiary, means may be taken to limit the formation of sugar by suitable hygienic and medicinal treat- ment. It is convenient to treat of these sepa- rately, though they should be employed in conjunction. jkeletic treatmmt. — All authorities agree that meat should be the main constituent of the pa- tient's food, and that starch, ajid cane and grape sugar, should be avoided, as well as the sub- stances containing them. The use of fats and oils, of fruit-sugar (levulose), and olm^lk-^ugar, is not so definitely settled. Three of the ordinary constituents of meat — gelatine, glycogen, and glycftrine — being sugar-formers, the parts of ani- mals containing these should as far as possible be avoided. It is very important in constructing a diet scale to give the patient as much variety of form as possible, the basis remaining the same. As the diet of the patient is the main factor in bis. treatment, it is worth the practitioner's whileto' Btiidy ^e various changes and combinations- of food which may be given with impunity. (See a 23 long list of available dishes in ihe Appendix of Bouchardat's work on Diabetes.) As regards vegetables, the rule is that all green vegetables, or the green parts of vegetables, may be eaten ; for where chlorophyll is abundant, starch and sugar are commonly scanty ; but this rule has important exceptions, which will readily occur to the reader. Thus the green parts of asparagus and celery may be used, whilst the white portion is highly saccharine. Green artichokes may be used. ■ Jerusalem artichokes are objectionable. Cabbage should be used before it forms a white heart. Cauliflower and brocoli are rather ques- tionable. Scottish kale and spinach may always be used. Sea-kale is forbidden. Most fruits are forbidden, but nuts may be used if they can be digested. French beans may be used when quite green ; when older the beans themselves must be removed. Haricot beans, peas, and all cere^ils ; tapioca, sago, arrowroot, all forms of macaroni, potatoes, carrots, turnips, parsnips, and beetroot are in the forbidden list. Water- cress, lettuce, and all kinds of green salad may be freely used. Cheese, especially of the poorer kinds, may be used. Cream, butter, and other fatty articles may be used in moderation, as they are only sugar-formers by virtue of the glycerine they contain. Some kinds of green pickle are useful ; mustard pickle should not be used. Most mustard contains starch, but it may easily be got quite pure. To sweeten tea or coffee, mannite has been suggested ; but both will soon be found more refreshing without sugar. Cocoa made from the nibs can be used. Small quantities of cold tea without milk or sugar, with slices of lemon in it, will often be found palatable, cleaning the mouth and relieving thirst. Einsing the mouth with iced water will often give more relief than a hearty draught. Slowly sucking ice is a very good plan for relieving thirst. All sweet drinks are in the forbidden list, including most sherries and ports, though some of the jformer may be found nearly sugar-free. Nearly all brandies contain sugar. LigW French and German wines contain little or no sugar. Gingerbeer and lemonade are very objectionable; so are champagne, sweet beer, cider, porter and stout, rum and gin. Whisky is probably " the best form of spirits. The use of alcohol in these cases has been gravely questioned.. Where alcohol has not been used before the , onset of the disease, the patient is probably better without it ; but it is quite clear that in many cases it may be taken in modera- tion with advantage. There is difficulty in procuring a, substitute for bread and potatoes. Three imperfect sub- stitutes are, employed, viz : — gluten bread, bran bread, and almond bread. Gluten bread as in- troduced by Bouchardat consists of flour out of which nearly, but not quite, all the starch has be^^n>ashed. It is tough, and patients tire ol it ; a better form of gluten bread is made by Bonthron (Eegent Street, londoij). This last is palatable and nearly starch-free, but does not keep well. Bran bread is now often made, in tha form of biscuits or cakes; tlie bran shoiild always be washed nearly free of flour. Bran bread is hardly admissible when there is a tendency to diarrhoea, but may be useful in constipatioa 854 DUBETES MELLITUS. Almond cakes -were first introduced by Dr. Pary. They are rather rich to be eaten -with meat, bnt used by themselves or with wine are excellent. Almond flour may now be obtained frcm which much of the oil has been expressed. We pass over Dr. Donkin's skim-milk treat- ment of diabetes with the remark that in the hands of Dr. Donkin and some others the method has been successful ; in the hands of many eminent physicians, both at home and abroad, it has done unmitigated harm. Probably the ex- planation of any successful cases may be found in the fact, that in certain conditions of diabetes, milk sugar, as weU as certain other substances, does not give rise to grape sugar. If milk is to be used, butter-milk or sour milk will be best. The treatment by sugar or glycerine is self-con- demned. Hyqienit) treatment. — In this the first and most important point is regular exorcise, espe- cially walking, not carried out to fatigue. Bouchardat has strongly advocated gymnastic exercises. These would be useful in moderation, especially in bad weather. Nothing is more grateful or beneficial to the skin after such exercise, or even without it, than a warm bath, temp. 80° to 00°, with a little common washing soda in it. In all cases, the avoidance of wet and cold is important. Plannels, frequently changed, should be worn ; and it is always safer to change the clothes after the slightest exposure to damp. Little may euf^ce to give rise to a fatal pneumonia. MediciTial Treatment. — This must be con- sidered as subsidiary to dieting, but there are many cases where undoubted benefit results from drugs. Of those which have been found of real value, the foremost is opium. Yet there is no unanimity of opinion as to the mode in which opium acts, and its apparent effects are most discordant— in some cases reducing both sugar and urine without sleepiness, in others speedily giving rise to drowsiness and even apparently to coma. The varied susceptibility oi difTerent patients to this drug is very striking. Some will take 20 or even 50 or 60 grains a day with no apparent physiological effect beyond slight contraction of the pupil; others again cannot en- dure even a few grains. The writer's experience is decidedly in favour of opium. Codeia has been strongly recommended by Dr. Pavy as being the influential ingredient in the raw opium. He begins with doses of half a grain. Next to opium come alkalies, and especially some alkaline waters. Alkalies themselves may be given in various forms — as cream of tartar to relieve thirst, as citrate or bicarbonate of potash, or, if there is a tendency to gastro-intestinal catarrh, as liquor potassae, with or without a bitter. The waters in most repute in diabetes are those of Carlsbad. Vichy, and Vals. An annual visit to Carlsbad, with the rigid system of regimen and dietary carried out under the resident physi- cians, often suffices, with due care, to keep the patient fairly well for many years. Lactic acid has been strongly advocated by Cantani. His results seem good, but he also makes use of a most rigid dietary. Dr. B. Fos- tei;record8 a case where acute rheumatism seemed to arise from the use of lactic acid. Pepsine DIAPHORETICS. and rennet' have been used, but without real advantage. Of secondary remedial agents, the three most iBiportant are strychnine, iron, and cod-liver oil; these favour nutrition, and the cod-liver oil seems to improve the temperature somewhat. Laxatives, not purgatives, should be used for the troublesome costiveness. Mineral waters, eastor- oil, or alkaline purgatives suit best. Management of a Case of Diabbtes.— By way of recapitulation we may say a few words here on the management of a case of diabetes, When a patient comes under the care of tlis practitioner he must first ascertain the general state of the patient as a basis for futui'e com- parisoin. The patient's weight must be carefully taken, and the state of his bowels noted. The quantity and characters of urine passed should be noted daily for a short time, the patient' still consuming ordinary diet. After a day or two the restricted diet should be gradually com- menced, sugar and potatoes being first cut off. Next the bread should go, being first of all cut down and used toasted hard or torrefied, and this should merge into the use of bran ctikts or gluten bread. Above all things, the patient must not be disgusted with his food, for this favours the secret consumption of forbidden diainties. Week by week the weight should be taken ; day by day the sugar estimated, as may easily be done by Roberts' method, and the whole arranged on a card so as to be seen at a glance. Warm baths, exercise, and the other adjuvants must be assiduonsly employed, and as soon as the effects of the limited diet are clearly marked, opium may be tried. If well borne it should be used deter- ihinedly, and pushed to its physiological effects, as indicated by the contracted pupil. If the patient is seen daily his diet should be regulated each day; if only at intervals certain available changes should be indicated. When convales- cence begins, and the urine has for some time been free from sugar, the diet may be gradually relaxed, beginning with substances containing little starch or sugar, gradually, extending to bread in small quantity ; potatoes should come last, sugar itself never. When, with every care, restriction of diet effects no diminution of sugar, or, if that be limited, emaciation apd weakness rapidly, go on, it will be a question whether it may not be best, as it often is,' to return to a practically unrestricted diet. Alexander SiLTii«. DIAGITOSIS of Disease. See Diskask, Diagnosis of. DIAPHOBESia (Sia, through, and ^opt*, I convey).— The act of perspiring. The term is more generally applied to perspiration artificially induced. DIAPHOBETICS (Siet, through, and ^opif, I convey). Definition. — Remedies which increase the secretion of sweat. When the increase is so great as to cause the perspiration to stand in beads upon the surface, they are usually termed sudor^fics. DIAPHORETICS. Enumkbation. — The principal diaphoretic meaaures are — The Vapour Bath, Turkish Bath, and Wet Pack ; Warm Drinks ; Warm Clothing ; Jaborandi, Pilocarpin ; prepirations of Antimony; Ipecacuanha; Opium and Morphia with their preparations; Sarsaparilla, Guaiacum, Serpen- tary, Sassafras, Senega, Mezereon, Camphor; Sulphur; Ammonia and its Carbonate, Acetate, end Citrate; Alcohol; Ethers (especially Nitrous Ether); and Chloroform. AcTioif. — The secretion of sweat usually con- sists of two parts, namely, a free supply of blood to the eweat-glandsi and the abstraction from it of the materials for sweat by the cells of the gland. These two processes sometimes occur independently of each other. In fevers the supply of blood to the glands is abundant, but they do not secrete ; and a similar condition is observed in belladonna-poisoning. Belladonna or atropia possesses the power of paralysing the secreting nerves of the sweat-glands, just as it does those of the salivary • glands, and thus the skin remains dry, although the cutaneous vessels are much dilated. In collapse the cutaneous glands secrete a cold sweat profusely, although tlie supply of blood to them is deficient. The secreting cells appear to be under the influence of nerves, by exciting which secre- tion occurs. The centres for the secreting nerves of the sweat-glands appear to be situnted . in the spinal cord, and in the medulla oblongata. The fibres seem to ran in the same path as the vaaoimotor nerves. The secretory nerves of the sweat-glands may bo excited directly by a stimulation of the nervous trunks in which they run ; and the sweat-centres may also be reflexly excited by irritationof various sensory nerves. Certain substances, such as nicotine and carbonic acid, seem to stimulate the sweat-centres ; whilst other drugs, such as pilocarpin, appear to act upon the peripheral terminations of the secretory nerves in the sweat-glands themselves. Several remedies, at the same time that they excite secretion, likewise increase the flow of blood through the skin, rendering it redder, warmer, and more vascular. Others, agaiiiy excite the secretion at the same time that they diminish the cutaneous circulation) Diaphoretics have therefore been divided into two classes, the former kind being termed eiimidant, and the -latter Mrfaijve idiaphor?tics. 'The exact mode in which each drug already enumeratedproduces diaphoresis has not yet been aseeirtained, but antimony, ipecacuanha, and jaborandi are classed as sedative diaphoretics, and all the others as stimulating ones. The supply of blood and the secretion are both increased by the application of *armthyby the ingestion of warm fluids, and by the action of j&borandi. UsBs.-t-Diaphoretics are employed to increase the flow of blood to the surface, and possibly to aid the elimination' of excrementitious pro- ducts in internal congestion, such as catarrh of the respiratory passages or digestive tract, and in febrile conditions generally. In fevers, the cutaneous circulation is generally active, and the so-called sedative diaphoretics are then most useful. Diaphoretics are also tised to increase the elimination of water by the skin, and thus lessen the accumulation of fluid in DIAPHEAGM, DISEASES OF. 866 dropsy, or to relieve other excreting organs, such as the kidneys in albuminuria and diabetes insi- pidus, or the intestines in diarrhoea. In these cases stimulant diaphoretics are indicated. T. LiUDBB BEnNTON. SIAFHBAaM, Diseases of.— The dia- phragm may itself be the seat of functional disturbance, or of ortianie lesions; or it may bo affect'cd by nHghhouriry morbid conditions. For practical purposes its affections may be con- veniently discussed according to the following arrangement: — 1. Mbchanical Interfekbitce. 2. FcNCTioNAi. DisoEDEus. (fl) Paralysis. (6) Spasm. 3. Obqanio Lesions, (a) Injuries, including Ruptiires and Ferforations. {b) Inflanuuar tion, acute or chronic, (c) Muscular Bheu- matism. (d) Atrophy and Degeneration. (e) Morbid formations, 1. Mbchanical iNTEKFBEENCE.-^The dia- phragm is frequently interfered with by morbid conditions within the chest or abdomen, which impede its action, displace it more or less, either upwards or downwards, or render it tense and stretched. The entire structure may be thus affected. Or only a portion of it, such as one lateral half or its central part. The chief tho- racic conditions by'Whioh the diaphragm may be thus affected are pleuritic effusion or pneumo- thorax, emphysema of the lungs, abundant peri- cardial effusion, enlargements of the heart, and tumours within the chest', The prineipaJl ab- dominal conditions deserving notice as being liable to produce this effect are a distended stomach, tympanites, ascites, peritonitis, preg- nancy, large faecal' accumulations, and tumours or enlarged organs which attain considerable dimensions, especially ovarian, hepatic, splenic or renal tumours. It sometimes happens that the dia^phragmis interfered 'vrith both from its thoracic and its abdominal aspects. The symptoms induced by this mechanical interference are readily explained by its effects. A sense of uneasiness and discomfort is often experienced around the lower part of the chest, amounting sometimes to considerable tension and tightness. There is not any actual pain, but in some instances, where the diaphragm is •muohipushed down, the patient complains of a painful 'Sensation referred to the ensiform car- tilage,' as if the attachment of the diaphrs^m at this point were being severely dragged upon. The act of respiration is more or less impeded, and this often seems to be the cause of the dis- comfort experienced. Asensation frequently com- plained of by patients is that they cannot take a lull breath. Eespiration may be much hurried, or oppressed and laboured, and not uncommonly the normal relation between the thoracic and abdominal movements is markedly^ altered, as observed on physical examination, and the diaphragm may so act as to draw in the lower part of the- chest-walls in inspiration. Occa- sionally a kind of spasmodic cough seems to be excited by the tension of the diaphragm pro- duced by certain conditions. The act of cough- ing is also frequently rendered more or less diffi- cult and ineffectual. B56 DIAPHRAGM, DISEASES OF. 2. Pdnotional Disobdehs. — The affections of the diaphragm included irithin this group are (a) Paralysis ; (A) Spasm. a. Paralysis. — The diaphragm is completely- paralysed when the upper part of the spinal cord is destroyed, whether as the result of injury or disease. If one or both phrenic nerves should be cut across, or destroyed by disease, or even se- verely compressed, the same effect will be pro- duced, either one lateral half or the whole of the diaphragm being paralysed, according as one or both nerves are involved. This structure may also be implicated in the course of diphtheritic paralysis. Where paralysis of the whole diaphragm is suddenly produced, death speedily ensues from the grave impediment to the respiratory func- tion resulting therefrom. If it is brought about gradu^ly, or if only part of the struc- ture is involved, the effects are seen in more or less interference with this function, and with the acts in which respiration is concerned. Thus there will be a subjective sensation of dys- pnoea, andof a want of power to breathe ; whilethe respiratory movements will be hurried, shallow, and superior-thoracic. Coughing cannot be per- formed efficiently, and sputa cannot be expelled, whilethe abdominal acts for which a tense dia- phragm is required, such as defeecation or yomit> ing, are also ineffectual or impracticable. The lower parts of the lungs become more and more congested, fluids accumulate in the air-tubes and pulmonaiy vesicles, which become by degrees filled up, and the patient ultimately dies of asphyxia. b. Spasm. — The diaphragm maybe the seat either of clonic or tonic spasm or cramp. The disorder may depend upon disease of the nerve- centre at the origin of the phrenic nerves ; irri- tation of these nerves in their course; direct excitation of the diaphragm ; or reflex causes. Tonic spasm is most strikingly observed in cases of tetanus ; of poisoning by strychnia, or of hy- drophobia ; but a form of asthmatic attack has also been attributed to this condition of the diaphragm. < The symptoms will vary in different cases. Tonic contraction of the diaphragm gjves rise to severe pain, and a sense of constriction in the corresponding region, which may come on in paroxysms ; clonic spasms also originate painful sensations after a time, which may become very considerable. Hiccup is probably due mainly to a clonic spasm of the diaphragm. If this structure should become rigidly fixed, respira- tion is gravely interfered with, and the patient soon presents the phenomena of suffocation, ■which will end fatally if the spasm is not re- lieved. In the form of asthma supposed to be due to diaphragmatic spasm, expiration is very difficult and greatly prolonged, inspiration being short and abrupt; the lungs are distended; great distress is felt; and there may be signs of impending death from suffocation. A spasmodic eongh may be due to clonic spasm of the dia- phragm. 3. OaoANic LvsioNs These may be briefly considered in the order in which they were enu- merated at the commencement of this article. a Injury, Perforation, and Kupture.— The diaphragm may be perforated, lacerated, or ruptured in connection with various forms of injury, such as crushing accidents, fractured ribs, penetrating wounds, or gun-shot injuries. Should the patient recover, a permanent perfora- tion may be left. In medical practice perfora- tion of this structure may be met with as a eon- genital condition ; as the result of the bursting of some fluid-collection through it, such as an empysema, a hepatic, renal, or other abscess, or a hydatid-cyst ; or from its destruction in the progress of some organic lesion, such as malignant disease or an aneurism. It may occasionally occur, independently of these causes, owing to the yielding of a weak portion of the diaphragm, especially between the attachment to the ensiform cartilage and the seventh rib. In rare instances the perforation is congenital, or a considerable portion of th^ diaphragm may be deficient. The size and other characters of the perforation differ much in different cases. If it is produced by the opening through the diaphragm of a fluid-accumulation, this fluid escapes from the abdominal into the tho- racic cavity, or viee versA ; in other instances the portions of the thoracic or abdominal organs pass through the perforation, constituting forms of diaphragmatic hernia. The writer had the opportunity of observing a remarkable instance in which the entire stomach had passed through an opening in the diaphragm into the cavity of the chest. In a case reported by Dr. Little, of Dublin, the dii^phragm presented an almost circular opening, well-defined, sharp, with some- what thick edges, and through this opening passed a hernia consisting of peritoneum con- taining some omentum, and about fifteen inches of the transverse and descending colon. To recognise clinically a perforation or rup- ture of the diaphragm is generally no easy matter. Often there are no symptoms referable to this structure, though there may be signs indicating that its functions are more or less impeded. The occurrence of sudden perforation may be known from the previous existence of some condition likely to cause this event, such as empyaema, or an abdominal abscess ; the super- vention of acute pain, accompanied with indica- tions of shock or collapse, and the disappearance of the signs of the original morbid condition ; and followed by the development of phenomena re- vealing that fluid has passed through the dia- phragm, and accumulated in the thoracic or abdo- minal cavity, as the case may be, or that some secondary affection has been set up as the result of the perforation, such as peritonitis or pleurisy. A fluid collection may, however, penetrate the diaphragm without giving rise to any very evi- dent disturbance. 'WTien an organ passes through the diaphragm, the symptoms present, if any, are more likely to be associated with this oigan than with the diaphragm, and physical exanu- nation may possibly detectthe displacement. In the case of hernia of the stomach, already re- ferred to, the chief symptom was vomiting, which occurred immediately after taking any food oi drink. b. Inflammation. — ^The serous covering of the diaphragm, either on its thoracic or abdomi- nal aspect, is not uncommonly involved in cases DIAPHRAGM, DISEASES OB of acute pleurisy or peritonitis respectively, and the inflammatory process may penetrate its structure. It may also be involved by extension from pericarditis. Inflammation of the substance of the diaphragm may further arise from injury, direct irritation, pysemia, or -without any evident 3au8e. The anatomical conditions observed are in- creased vascularity; the formation of lymph upon its surfaces; softening and degeneration of its museular tissue ; or, in rare iustances, suppura- ■jon, an abscess forming in the substance of the diaphragm, or pus collecting under one or other of its serous coverings. Chronic inflammation of the diaphragm may occur, leading to a fibroid change in its muscular portions, either by exten- sion from neighbouring structures, or as the result of chronic local irritation. The symptoms of acute inflammation of the diaphragm are generally very obscure and ill- defined. The condition may be indicated by severe pain in the region of this structure, obviously increased by breathing, so that the respiration becomes instinctively thoracic, as well as hurried and shallow; and also much aggravated by coughing, defecation, or any other act -which disturbs the diaphragm. The patient will probably be much distressed. More or less pyrexia will probably be observed. If an abscess should form, this might burst either into the chest or abdomen, and thus lead to secondary pleurisy or peritonitis. Chronic inflammation and its cousequences may possibly be snspected from a want of free movement in the diaphragm, associated with conditions likely to originate this change ; but it could scarcely be recognised with any certainty. 0. Muscular BhetunatiBm, — The diaphragm may be involved in this complaint, what^ever its nature may be; probably it is attended with Blxuctural changes in its tissues. The affection is characterised by pain referred to the dia- phragm, which may be very acute when it is in any way brought into play. So long as it is kept at rest, there may be no discomfort, but deep breathing causes considerable pain, so that the respiration is carried on in a shallow manner, and may be entirely thoracic. Such acts as coughing or defsecation cause much pain and a sense of aching. d. Atrophy and Begeneration.^The dia- phragm may be involved in the course of pro- gressive muscular atrophy ; it may also be atrophied from causes which produce general wasting; or undergo senile atrophy and degenera- tion ; or be similarly affected from local causes, such as interference with its blood-supply from vascular degeneration, want of action, or after chronic inflammation. These conditions might give rise to more or less evident interference with the functions of the diaphragm, which in extreme cases would amount to their total cessa- tion, diaphragmatic breathing being rendered impossible, the symptoms being then the same as when the diaphragm is paralysed. In cases of progressive muscular atrophy the fatal ter- mination may arise from this cause. There would not be any pain, but uncomfortable sensa- tions might arise from the impeded respiration. e. Morbid Formations. — The diaphragm ia occasionally the seat of malignant disease, being DIAERHOEA. 887 usually involved by extension from sotne neigh- bouring structure. Non-malignant solid growths have in rare instances been found in it. Parasitic formations may also occur in it, namely, hydatids, cysticercus, and trichina spiralis. Tubercle is occasionally found in the diaphragm. Possibly malignant disease might be indicated by signs of impededdiaphragmatic movements, with localised pain, accompanying indications of cancer in other parts. The implication of the diaphragm in trichinosis may also be recognised in some in- stances by severe pains, spasmodic contractions, and serious interference with diaphragmatic respiration. In most cases, however, the pre- sence of any morbid growth in connection with the diaphragm cannot be diagnosed during life, and is only discovered at ttie post-mortem exa- mination. / Tbeatmknt. — ^But little can be done in most cases in the way of direct treatment in connec- tion with affections of the diaphragm. The most obvious indication is to get rid, if possible, of any condition which is mechanically impeding its movements, and preventing it from performing its functions. In the next place, any disease of which the condition of the diaphragm is but a part must receive due attention, such as progres- sive muscular atrophy, centric nervous disease, or trichinosis. Painful affections might be re- lieved by local applications of dry heat, fomenta- tions, or anodynes; and if acute inflammation is suspected, a few leeches might be applied. Electricity might prove of service in the treat- ment of some cases of spasm or paralysis of the diaphragm, the continuous current in the one case, the interrupted current in the other. Feedebiok T. Eobebts. DIABBHCEA {Slappfa, I flow away). — SnfON. : Defluxio; Aim Fhtxue; Pwrging; Fr. Cours de Ventre ; Bevoyement ; G-er., Der Durchfall ; Satiolijluss ; BurcUmtf. Definition. — ^A frequent and profuse discharge of loose or of fluid alvine evacuations, without tenesmus. MnaiMGi. — The causes predisposing to diarrhosa are individual peculiarity; childhood -^especially the period of first dentition; the climacteric period ; and hereditary or acquired weakness of the digestive organs. — The exciting causes may be thus classified ;— 1. Direct irri- tation of the intestines by (a) Food in excess, or of improper quality — for example, salted meat, shell-fish, sour unripe fruit and vegetables — dis- eased, decomposed, or imperfectly masticated ; the products of faulty digestion prematurely passing the pylorus ; imperfectly elaborated and fermenting chyme ; impure water, such as that containing from 3 to 10 grains of putrescent animal matter per gallon (Parkes) ; or imper- fectly fermented malt liquors. (J) Purgative medicines and irritant poisons, (c) Bile, excessive or acrid, {d) Faces, retained, (e) .Bntoeoa — lum- brici, taenia, trichinae, and entophyta — mycosis enteralis (Buhl and others). (,/) The contents of a ruptured abscess or hydatid cyst, (g) Intestinal lesion — such as tubercular or other ulceration. 2. Defective hygiene. — Diarrhoea may arise from the dwelling being damp, cold, dark, and unventi- lated; or. fropi foul emanations from decaying 858 DIARRHCEA. OTganio, especially animalroatter, sewage, ortecal collections. 3. Chills, climatia variaiiom, &e. Diarrhcea has been attributed to insufficient clothing; sudden exposure to cold and damp; chills, as fromiret feet, and damp bed or clothing ; OTei^heating, as by excess of bed-clothing ; and rapid variations of temperatuie, such as hot days and cold nights. 4. Nervous dUtwbances, for exr ample, depressing emotions — ^fright, grief; neu- ralgia, hepatalgia (Trousseau), dentition, and other causes of Teflex disorder; 5. Defective absorption with augmented peristalsis, so that the food is passed unaltered — Lienterio diarrhcea. S. Symptomatie in various morbid states, for in- stance, in passive congestion of the portal vein from disease of the liver, heart, or lungs ; perito- nitis, especially puerperal; organic disease cf the intestines — ulceration (simple, typhoid, tu- bercular, cancerous), lardaceous degeneration, enteritis, acuta or chronic; cholera; typhoid fever ; dysentery ; occasionally in pyaemia, measles, scarlatina, confluent small-pox, ma- laria, gout, Bright's disease (its later stages), and in anaemia and exhaustion, as from oveiv lactation, phthisis, cancer, Addison's disease, Hridgkin's disease, exophthalmic goitre, leueo- cythsemia, and other affections. Frequently diarrhoea arises from- the combined action of several exciting causes, as ■when the disease is epidemic during summer and autumn Foul emanations from decomposing organic mat- ter, over-crowding, food (and especially fruit) in a state of incipientdecay, excessive heat, and chills, may then collectively determine the result. In children the exalted irritability of the nervous system during dentition predisposes to diarrhcea from slight determining causes. Dksceiption and Varieties. — Diarrhcea may be broadly divided into the aewte or occasional, and : the chronic forms ; and the numerous clinical and pathological pecidiarities of different cases are conveniently grouped into typical varieties. The general effects, varying according to the inten- sity and duration of the flux, are mainly these: — Emaciation, and, inohildren, also arrest of grovrth — theweight either diminishing or ceasing to be progressive ; anaemia, indicating defective haema- tosis ; desiccation of the tissues from the rapid draining of serum from the blood — hence the thirst, and the very concentrated, acid, and even albuminous urine observed when there is a copious watery outflow from the bowels, as in choleraic and similar forms of diarrhoea. It will be expedient to describe briefly the principal forms of diarrhcea. 1. Irritative Diarrhoea. — Stkoit. : Diarrhcea Oraptdosa (Cullen). — Simple flux from direct irritation of the intestines is the most common variety of diarrhoea. The evacuations, usually preceded by severe griping pains, are at first faeculent and usually fetid and sour, then watery. In children (especially hand-fed) they are often like pale clay or putty, or they contain dense masses of undigested casein before being loose ; after evacuation they frequently become green- ish, like chopped spinach, from contact with very concentrated acid urine converting the brown colotring matter of the bile into green biliverd in ; or they are dark green when passed, and may be BO acrid as to excoriate the anus, the genitals, the inner parts of the thighs, and even the heek Fever is usually absent. Diarrhoea from irritation is frequently a pre- liminary stage of the inflanmiatory, dysenteric, and choleraic varieties. 2. Inflammatory Diarrhoea. — Synok. : Diar- rhoea Herosa. — ^When the causes of simple irrita- tion excite inflammation of the mucous membrane of the bowels, fever sets in, and the diarrhoea in- creases. Usually the evacuations become mors serous, and contain shreds of fibrin or mucus or pus. Before the attack passes off the large bowels are apt to be the main seat of inflammation; then the motions are scanty, frequent, more mucous or glairy, contain streaks of blood and are passed . with severe straining ; while , tJia skin is hot and dry. < 3. Choleriform Diarrhcea — Stnok. : Cho- leraic diarrhoea ; Thermic diarrhoea *- prevails mostly in hot weather. The onset, indicated by vomiting and purging, is usually sudden. At first the vomited matters are mucous and bile- tinted, and the dejections are feculent — botli quickly, however, becoming more and more abun- dant, watery, and colourless. The copious and incessant outflow of serum may in a short time, and especially in children, induce a striking re- semblance to the symptoms of Asiatic cholera — a drawn, sunken, and cyanotic appearance, loss of temperature, scanty secretion of urine, insatiable thirst, and cramps ; even in extreme cases the fluids from the stomach and bowels are, how- ever, rarely free from bile, and are not so like rice-water as in true cholera. The collapsed algid condition as a rule rapidly gives place to recovery in previously healthy adults, while it is fatal in delicate children, children prematurely weaned, the debilitated, and the aged. Barely, the cold stage being outlived, the patient becomes hot, and passes into a state of stupor, with either bilious vomiting or purging and tympanites — the typhoid stage. In children death is almost invariable if the cold stage exceeds twenty-foui hours. 4. Hervous Diarrhoea. — ^Theperistaltieanove- ments, and the activity of the glands of the ali- mentary canal, are often increased by causes operating through the nervous system. Diar- rhoea from mental, and especially emotional, per- turbation, is the most common example. Even a chronic looseness may be maintained by de- bility of the nervous system, induced by wony and anxiety. Exalted innervation of the bowels may be natural, a proneness to diarrhoea from slight exciting causes having always existed; or acquired, when, for instance, a flux once estab- lished is apt to be maintained. The unstable nervous system of the periods of rapid develop- ment and of the climacteric change-predisposes to it. It is often an important factor in chronic diarrhoea. The intestinal nerve-centres may become so sensitive (as in delicate children) that every meal, however small, may induce an immediate call to stool, the motions being liquid or pultaceous, and pale, but otherwise healthyi The peristaltic movements may be even so in- creased £^s to hurry the food through the stomach and bowels, so that it appears unchanged in the stools. Time is not allowed for digestion or absorption to be even begun. This form has DIARRHCEA. Sfib been termed Diarrhcea Uenierica, and is most fre- quent ill children before the period of the second dentition. The increased tonicity of the mus- cular fibres of the alimentary tract may have resulted from previous inflammation of the mucous surface, or is the propagation upwards of some irritation (ulcer, inflammation, &e.) of the mucous membrane of the rectum ; or it arises from the products of imperfect primary diges- tion entering the duodenum. In adults indi- gestion is the usual cause. The appetite is. as a rule voracious, and debility may become extreme. In painful or difficult dentition, diar- rhoea arises from irritation of the nerves of the stomach and bowels ; digestion is arrested, and the ' contents of the alimentary canal become acid from fermentation, and are ejected by vomiting and purging. , 5. Ticarioua Diarrhc9a. — ^Embarraasmentor suppression of the functions of the skin, kidneys, or lungs may be met by the bowels performing additional excretory work. The flux thus set up is salutary, because it is compensatory. Diar- rhoea from chills (suppressed perspiration) is a common instance, while that from renal and pulmonary causes is less frequently observed, and may be misconstrued by the practitioner. Inasmuch as diarrhoea usually diminishes the quantity of urine, even sometimes to the verge of suppression, the reverse of this clinical fact may be easily overlooked or misinterpreted. Even lyheu forewarned, the observer may at tinjes^-rcspecially Tf hen the urine is free from albnmen — find it difficult to determine whether the diarrhcea is a cause or an effect of imperfect renal elimination — a distinction having all- important bearings on the treatment. The uraemicand eliminatory character of it may be easily decided vhen the kidneys are known to be diseased ; not so, however, when the only , thing ascertainable is scanty — maybe albumingus— urine, or total sjippression of urine in an elderly patient. In such fk ease there may or may .not be organic disease of the kidneys, and still the diarrhoea may be: ursemic, inasmuch as it may depend on ' renal inadequacy.' Diarrhoea from pulmonary embarrassment generally affords re- lief to breathing and cough. The chronic loose- ness of some gouty patients is also eliminatory : when, checked, gout is apt to advance and the health to suffer. 6. Diarrhcea from mechanical congestion. — Draining of serum into the bowels is a common result of overloading of the portal vein from an impediment to the flow of blood, either in the vein itself, the vena cava, or the right side of the heart. 7., Chronio Diarrhoea. SnJou.: Cachectic diar- .rAao.— Chronic diarrhoea is frequently, if not generally, unconnected with intestinal lesions; it may be maintained by chronic catarrh of the in- testines, or by an exhausted and impoverished state of the system, as in inanition, either from insufficiency of food or from enfeebled digestion, or in .clironic wasting diseases, such as syphilis, nialaria, or scurvy. The flux increasing, the debil- ity on which it depends thereby perpetuates itself, and this vicious cirde tends more and more to destroy life by ansemia and exhaustion, and even after apparent recovery there is a strong dis- position to revert to it. These clinical features of chronic diarrhcea are well illustrated by the malady which, from the paleness of the stools, is commonly known in India as ' White Flux' — a result of deterioration of health by climate and malaria. Wlien accompanied by fever and night- sweats, chronic diarrhoea is nearly always due to tuberculisation. Diagnosis. — ^The different forms of diarrhoea may be readily distinguished from each other by a careful consideration of the causes and symp- toms. The diseases most apt to be mistaken for diarrhoea are epidemic cholera, dysentery, and mucous irritation of the bowels from retention of fseces. a. Cholera, in its less definite, forms, may re- semble bilious diarrhoea and choleraic diarrhoea. The probability in favour of it may be deter- mined by the absence of the ordinary causes of didxrhoea, the paleness and watery character of the stools, tormina being slight or absent, the sup- pression of uvine, and the early exhaustion. The presence of bile in the stools is always in favour of diarrhoea. Vomiting is more frequent in cholera ; when it occurs in diarrhoea the vomited matter usually contains bile and undigested food, while in cholera it is a colourless fluid. b. Dysentery is usually characterised by fever, tormina, and tenesmus, and frequent scanty muco-sanguinoljent evacuations. Sometimes, however, in the early stage, the motions are copious, watery, and fseculent, as in ordinary diarrhcea; but the presence of tormina and tenesmus, and tenderness in the regions of the caecum and sigmoid flexure, indicate the dysen- teric nature of the disease. Chronic diarrhoea may be distinguished from chronic dysentery by the absence of a history of acute dysentery, or of mucus and tenesmus, and the less frequent discharge of blood in the evacuations. c. Mucous irritation of the bowels. — Retention of faeces may induce a condition resembling diarihcea — frequent thin muco-faeoulent evacua- tions, which are, however, shown on enquiry to be somewhat scanty, and voided with straining. Treatment. — (a) Diet and hygiene. In acute or occasional attacks of diarrhosa, everything should be taken in small quantity, and tepid or cold, never hot. Farinacea — arrowroot, sago, rice,. tapioca, flour, and the like are useful, and may be taken in milk, or in chicken or mutton broth, or weak beef-tea. Animal broths^-and. especially beef-tea — when concentrated, or in large quantity, are apt to aggravate diarrhoea. Mucilaginous dritiks — white of egg in water or milk, rice or barley or arrowroot water; and astringent liquids — infusion of dried whortle- berries or roasted acorns, red light wines — may be given. Brandy is often of service, and may be mixed with spices or with the farinaoea. Lime- water with milk is in many cases of much value. Rest in bed secures a uniform warmth of skin, and favours the cessation of diarihoea. In children, errors of feeding should be cor- rected. Lumps of casein in the motions may he met by reducing the quantity of milk, and regulating the time between meals, providing a wet nurse, or substituting the milk of the goat or ass for that of the cow. Sometimes, however, milk in any form must be given np. The abdo- 360 , men should be protected by a flannel bandage, and the feet and legs by warm clothing;. ' Inasmuch as in ckronw diarrhaia the flux is perpetuated by the debility and ansemia which it induces, and by the activity of intestinal digestion, it has become a leading principle of treatment to prescribe food rich in materials for the construction of the blood and the tissues, and almost wholly disposed of by the stomach. Hence the happy results frequently observed from a. diet exclusively animal, either raw or lightly-cooked, the digestion of which may be aided by hydrochloric acid alone or with pepsin. Individual peculiarity may be gratified, and variety obtained from the use of mutton, veal, chicken, pigeon, and game. Beef, the tough parts of veal, and pork are, as a rule, to be avoided. Milk and farinacea are gradually permitted during the progress towards recovery, but the period during which they should be interdicted may require to be vety prolonged — even months. The treatment by raw meat, strongly advocated by Trousseau and Niemeyer, has been success- fully applied to nearly every variety of chronic diarrhoea, but especially to that obstinate one occurring from the time of weaning to the close of the first dentition. The meat may be pounded into a pulp or finely minced, then mixed with salt, sugar, fruit jelly, or conserve of roses, or diffiised through clear gravy soup or chocolate made with water or wine ; or the juice may be extracted from it by pressure. Notwithstand- ing the prohibition of other food, it is best to begin with a small quantity, and to increase it gi-adually. The only drink allowable is water containing white of egg. Trousseau found opium in small doses, chalk, and bismuth, at and between meals, to assist this regimen. When a restricted animal diet cannot be digested, causes loathing, or aggravates the flux, other varieties of food may be added, and the feeding should be as generous and varied as possible, and adapted to the digestion of the individual. Articles of diet appearing undigested in the motions should be avoided. Low and damp situations should be exchanged for dry and open ones. Warm clothing, flannel next the skin, and flannel waist- belts should be worn. (i) Medioiiml Treatment. — The kind and de- gree of interference required should first be decided in each case of diarrhoea. A routine prescription of astringents is much to be depre- cated. When the flux is moderate and salutary —for example, removing undigested or indi- gestible materials or irritating secretions, re- lieving an engorged portal vein, or supple- menting a suppressed secretion — it may be left uncontrolled by medicine, or may be encouraged by laxatives, such as castor oil, rhubarb, or a saline aperient, combined with a mild sedative — for instance, henbane' or opium: it cannot be checked without risk. As a rule, the treat- ment of diarrhoea should begin by removing irritating substances from the alimentary canal by aperients guarded by small doses of opium ; and astringents, such as chalk-mixture with tino, catechu, haematoxylum, and opium, should be held in reserve. A purgative may increase the flux, which, however, soon subsides. Trous- seau advocated the use of salines —sodas sulphas. DUEEHCEA. soda tartarata, magnesias sulphas — in progres- sively decreasing doses, dissolved in a small bulk of water, in the morning fasting, while others prefer castor oil, rhubarb, or other ape- rients. Castor oil is by far the most useful remedy for children, as well as for adults ; for the former it should be emulsified in gum and syrup, and for the latter in yelk of egg, and as occasion requires combined with a small opiate, for example, compound tincture of camphor, Tinum opii, or tincture of opium. In choleraic diarrkcea, th« best results are obtained from castor-oil guarded by a small dose of laudanum at the commencement, and repeated if the disease is severe; while astringents and opiates alone are withheld until the bowels' are relieved of offensive materials, as in the later stages, the stools being copious and watery, griping and distension of the abdomen absent, and the tongue clean. Vomiting should be en- couraged by copious draughts of warm water, and, if need be, by emetics of mustard or ipecacuanha. In children, when the motions are colourless, profuse, and incessant, it is best to give hydrargjrum cum cret4 in small doses every hour or two, and a very small enema of starch, containing phumbi acetas or cupri sulphas, witli laudanum, which may be repeated if necessary; and the urgency of the case may likewise demand a firm astringent, such as logwood. In the cold stage there ^ave been recommended mustard baths (for twelve or fifteen minutes, several tinves a day); emetics (ipecacuanha 2 to 3 grains twice or three times in twenty-four hours) ; diffu- sible stimulants (ether in syrup every hour or half-hour); and mercurials (hydrargyrum cum cr6t4) ; in the stage of reaction, saline aperients or calomel in small doses throughout, white-of- egg in water as a drink ; and, vomiting having ceased and diarrhosa being established, bismuth, chalk, and lime water. In nervous diarrkcea the first indication is to allay reflex excitability by the bromides, or, these failing, by opium. When diarrhcea is ex- cited by food, the dose should be given shortly before meals. In lienteria diarrhoea arsenic is invaluable. Mal-digestion should be met by hydrochloric acid, bismuth with alkalies, or other appropriate remedies, according to the indications. Occasional doses of castor-oil— alone, or with bismuth or small doses of opinm or henbane — are useful in clearing away fer- mentescible matters, which are apt to maintain an irritable state of the bowels. Astringents should only be prescribed after the failure of these or similar measures. In vicarious diarrhoea the skin should be made to act freely by warm baths, or hot air or vapour baths. In renal inadequacy counter- • irritation across the loins, digitalis, «nd nitrate of potash may be likewise indicated. The diar- rhoea should not be arrested or even cheeked unless it be profuse and exhausting, especially after restoring or augmenting the action of the s'-in and the kidneys ; it is sometimes advisable to nurse. and encourage it. Diarrhoea from passive congestion of the portal vein is to be met by treating the cause, for ex- ample, disease of the heart, by digitalis, iron, and other remedies. DIABEHCEA. The flux of chronic diarrhaa cannot as a rule bo stopped altogether by astringents only— the evacuations while thus retained may decompose, and induce flatulence and colic, or fever. The general health should be restored and anaemia removed; the secretions will then generally improve and the diarrhoea subside. Tonics — iron, arsenic, quinine, strychnia — may be aided by astringents — mineral acids, opium, bismuth, chalk, or hsematoiylum. The best prepara^ tions of iron are iron alum — 3 to 6 grains, and liqdbr ferri pernitratis — '10 to 40 minims. Ipecacuanha and taraxacum are useful when the skin and liver are inactive : from 1 to 3 grains of pulvis ipecacuanha may be given night and morning. Podophyllum — -2 or 3 minims of a solution of 1 grain in 1 drachm of rectified spirit three or four times a day — is indicated when the motions are watery, pale or high-coloured, and passed with severe cutting pains. Saline purgatives in the early morning are recommended — 2 drachms of sulphate of soda, sulphate of magnesia, or soda tartarata on the first day, then 1 drachm for fourteen days, dissolved in a small bulk of water, with avoid- ance of fluids after the dose — and from 1 to 2 grains of rhubarb, also taken fasting. The pro- fuse sweating and colliquative diarrhcea of hectic is best met by hsematoxylimi and dilute sulphuric acid, or opium with astringent mineral salts — nitrate of silver, sulphate of copper, or acetate of lead — by the mouth or rectum. Suppressed secretions, particular cachexise, disturbed innervation, congestion of the portal vein, and organic diseases of the intestines, form special indications for treatment when diarrhcea is present. Geoboe Ouveb. DIATHESIS (SiaxWufii, I dispose).— A morbid constitution, predisposing to the develop- ment of a particular disease. See Constitutioit, with whichi in a somewhat more limited sense, this term is synonymous. DIATHETIC DISEASES— Constitutional diseases. See CoNSTiTnTioN.u, Diseases. DICBOTI8M (S(s, double, and KpSTos,a, stroke) is a term applied to the second great w.ive of the pulse. This dicrotic wave or dicrotism is due to a second expansion of the artery which occurs during the diastole of the ventricle. The pvlstia bisferiem of old authors was a pulse in which a second beat became perceptible to the finger; an occurrence observed occasionally as an an- tecedent of haemorrhage and also in the course of fevers. The second beat perceived by the finger is not always the true dicrotic wavej but may in some cases be an exaggerated tidal wave. This is the wave perceived in the high arterial tension sometimes antecedent tohsemorrhage. The mode of production of dicrotism is not quite agreed on ; it is favoured by a low state of arterial tension, by elasticity of the arterial . coats, and by quick and strong ventricular contractions. It is generally considered to be central in its origin, and to be a wave of recpil from the closed aortic Valves reinforced by an oscillation set up in the aorta., ,. The other view refers the origin of the dicrotic wave to the periphery. The wave of DIET. 861 blood discharged at each ventricular systole is, in consequence of its acquired velocity, disturbed from its state of equilibrium, and, as a result of the resistance offered by the peripheral vessels, reflows towards the heart, whence it is again reflected. Bee Pulsb. EiXTHAZAii Foster. DIET. — Definition. — Diet may be defined as expressing the regulation of food to the re- quirements of health and the treatment of disease. General Pbinciples. — In order to sustain life, a diet must consist of a proper apportion- ment of the following alimentary principles: — 1. Nitrogenous principles. 2. Non-nitrogenous principles (fats, carbo- hydrates, &c.) 3. Inorganic materials (saline matters and water). Wliilst these principles hold different relative positions of value, the absence or defieiency of either group will render a diet unfit for the support of life. Milk, the product provided by Nature as the sole article of sustenance during the early period of the life of mammals, may be regarded as furnishing us with a typical dietetic representative of all these principles. The egg also holds a like position, and, us all the parts of the young animal are evolved from it, must needs comprise all the materials for the deve- lopment and growth of the body. The required principles are contained in food derived from both the animal and vegetable kingdoms, and the diet may be drawn from either ; but, looking to man's general inclination and the conformation of his digestive apparatus, it may_ be assumed that a mixed diet is that which is designed in the plan of Nature for his subsistence, and it is that upon which he attains the highest state of physical development and intellectual vigour. ' Animal food, being identical in composi- tion with the body to be nourished by it, is in a state to be more easily appropriated than vegetable food. It also appeases hunger more thoroughly and satisfies longer : in other words it gives, as general experience will confirm, greater stay to the stomach. Animal food pos- sesses stimulant properties which have sufficed in certain instances, as after starvation, and in those accustomed to a vegetable diet, to produce a state allied to intoxication. This stimu- lating effect is further illustrated ' by looking at the relative character of animal and vegetable feeders. Liebig says that it is essentially their food which makes carnivorous animals in general bolder and more combative than the herbivora which are their prey. He then relates that a bear kept at the Anatomical Museum of Giessen showed a quiet gentle nature as long as it was fed upon bread, but a few days' feeding on meat made it vicious and dangerous. The standard diet framed by Moleschott has been accepted as furnishing a model of what may be considered the requisite proportion of ali- mentary principles for maintaining health in a person of a,yerage stature under exposure to a temperate climate and a moderate amount of muscular work. It runs as follows : — DIET. Alimentary s'ubsiances in a dry state required "Dry Food Albuminous matter Patty matter . Carbo-hydratoB Salts . In ounces avoir. . 4-587 . 2-964 . 14-250 . 1-058 22-859 This, it will be seen, furnishes a supply of about 23 ounces of dry solid matter, and of this one-fifth is nitrogenous. If we reckon that ordinary food contains about 50 per cent, of water, then 23 ounces will correspond to46 ounces of solid food in the condition in which it is con- sumed. To complete the alimentary ingesta, a further quantity of from 50 ounces to 80 ounces of water may be assumed to be required to be taken daily under some form or other, ■ For a life of inactivity, it must be stated that a much smaller amount of food will suffice. The diet, for instance, which is ordinarily evipplied to the patients of Guy's Hospital, and which suffices to satisfy and properly sustain them, only contains about 30 ounces of solid food, equi- valent to about 17 ounces of water-free material. It has been mentioned that there are reasons for regarding a mixed diet of animal and vege- table food as best adapted to our nature, and it may probably be considered that the most suit- able admixture contains about one-fourth or rather more of animal food. Looked at from the following point of view, it will be seen that an admixture of animal and vegetable food more economically supplies what is wanted, than either kind taken alone, unless the adjustment should be made with the proper apportionment of fat as a representative of a non-nitrogenous article. It is estimated that for a man of medium stature, and performing a moderate amount of work, about 300 grains of nitrogen and 4,800 grains of carbon are daily required to be introduced into the system with the food, to compensate for the outgoing of these elements that occurs. Now this is yielded, as nearly as possible, iu the case of both elements, by 2 lbs. of bread and | lb. of meat — that is, 44 ozs. of solid food, of which about one-fourth consists of animal matter. If the lean of meat only were consumed, rather over 6 lbs. would be needed to furnish the requisite amount of car- bon, and there would be a very large surplus of unutilisable nitrogen ; whilst if bread only were taken, the amount necessary to supply the re- quisite quantity of nitrogen would la rather more than 4 lbs., and this containsnearly doubis the amount of carbon wanted. In order to preserve healtli it is necessary that a portion of the food consumed should be in the fresh state, and this applies to both animal and vegetable food. There may be no lack of quantity, and yet disease and death may be induced by inattention to this fact. Affeor tions of the scorbutic class are produced, which can only be checked and removed by the supply of fresh food or the juice of some kind of suc- culent vegetable or fruit. The efficacy of lemon and lime juice, for instance, is well known in the prevention and cure of scurvy. Climate influences the drmand for food, and instinct leads to the adaptation of diet to the requirements that exist. Not only is there a correspondence between the amount of food re- quired and the inclination for taking it, but the nature of tie food selected in different, councriej varies and stands in harmony with that which is most in conformity with what is needed. The dweUers in the arctic regions, besides consuming a large quantity of food, partake of that kind which abounds in the most efficient form of heat-generating material, namely, oleagiuoni matter. In the tropics, on the other hand, it is upon vegetable products, largely charged with principles belonging to the ciirbo-hydrato group, that the native inhabitants mainly subsist, ' Labour necessitates a supply of food in pro- portion to the amount of work done. The em- ployer finds that the appetite of a workman may be taken as a measure of capacity for work — in other words, that a falling off of the appetite means a diminished capacity for the performance of labour. Until recently, it was considered, in accord- ance with the teaching of Liebig, that muscular and nervous action resulted from an oxidation of muscular and nervous tissue, and that ac- cording to the amount of action occurring, go was a demand for the supply of nitrogenffinS alimentary principles created to replace the obd- dised material. It is now held, however, that the non-nitrogenons elements of food contribute, as well as the nitrogenous, to the production of muscular and nervous force. Fick and Wisli- cenus undertook a known amount of work upon a non-nitrogenous diet, and proved that tlie oxidation of their muscular tissue, as measured by the amount of nitrogen voided with the urine, sufficed only for the production of a small proportion of the force expended- in the acoom- plishment of the work performed. The musdes; in reality, appear to stand in the position of in- struments for effecting the conversion of the chemical energy evolved by the oxidation- of combustible matter into working power. Fats and carbo-hydrates can furnish the combustible matter required, and, under ordiniiiy circum- stances, probably do largely, if not chiefly, supply it. Nitrogenous matter can do so likewise, but it has to undergo a preparatory metamorphosis for effecting the separation of nitrogen in a suitable form for elimination. It must be said, however, that experience shows that'hard work is best performed under a liberal supply of nicrogen-containing food. The explanation of this probably is that it leads to a better-nou- rished condition of the muscles and of the body generally. Under the use, for iuKtance, of ani- mal food, which is characterised by its richness in nitrogenovis matter, the muscles are observed to be firmer arid richer in solid constituents than imder subsistence upon vegetable food. Persons who lead a sedentary and in-door life naturally require less food than those en- gaged in active work, and less should be con- sumed by them to prevent the system becoming clogged with effete products, which act per- niciously in various ways upon the body. The food should also be largely constituted of non- nitrogenous principles, as these tax the excretorv organs less than the nitrogenous. DIET. 363 . The diet of infants is a branch of dietetics the importance of which can scarcely be over- rated. The proper food during Uie first period of infancy is that which has been provided by Nature for the young of mammals, namely, milk, tip to about the eighth month the infarct is de- signed to be sustained solely. by its parent's milk. The teeth, which ordinarily b«gin to show themselres about this time, indicate that some solid matter should now be consumed, and one of the farinaceous products will be the most suitable with which to commence. Bread, baked flour, pjain biscuit, or one of the numerous kinds of nursery biscuits that are made, may be em- ployed for a time as a supplement to the ; former food. At about the tenth month the inothcr,, who ought previously to have commenced lessening her own supply, should now cease it altogether. As the child advances through its second year and the teeth become more developed, meat, preceded for awhile by gravy, may be given. If the mother cannot suckle her child, or a wet nurse, whose supply stands next best to that of the mother, be provided, the milk of one of the lower animals should be obtained, and that of the cow gives the nearest approach to what is wanted. Cow's milk, however, is richer in all its solid constituent principles than woman's, and the addition of a solution of sugar or-r-what is more in conformity with the natural supply — sugar of milk (lactine), in the proportion of an ounce to three quarters of a pint, is needed to bring the two in closer approximation. The milk of the goat is even richer in solid consti- tuents than that of the cow, and therefore stands somewhat further removed from that of, the human subject. If, hpwever, it is not a.dapted for infants, it is highly useful for improving the condition of badly-nov(rished children, and is sometimes employed for this purpose. Therapeutical Appucations. — The applica- tion of the principles of dietetics may be success- fully brought to bear in the treatment of corpulency and thinness. A diet rich in nitrogenous matter conjoined with exercise promotes the growth of muscln, but the fat undergoes no increase. The conditions most conducive to an increased accu- mulation of fat are a diet rich in either fat or carbo-hydrates (provided the requisite amount of nitrogenous matter be present for affording what i^ wsiuted for the nutritive operations of life), exposure to a warm atmosphere, and inac- tive habits. A supply of fat in a direct manner, leads to an increased deposition of fat in the system, but the carbo-hydrates require in the first place to undergo assimilative change before they can be applied in the same direction. The details of the dietary to be prescribed where the aim is to produce increased stoutness and an improved condition of the body, should comprise such articles as fat meats,, butter, cream, milk, cocoa, ohocqlate, bread, potatoes, farinaceous and flour puddings, oatmeal porridge, sugar and sweets, sweet wines, porter, stout, and ales. The converse mode of dieting is necessary for reducing stoutness, Mr. Banting, by his noted system of dieting, reduced his weight from ,14 stone 6 lbs. to 11 stone 2 lbs. in about a year. Besides altering, however, the character of his food, he limited the quantity in a manner that must have contributed an important share towards producing tie effect observed ; not more than twenty-two to twenty-six ounces of solid food (eorresponding with, eleven to thirteen onnces of water-free material) being consumed, according to his statement, in the t\*enty-four hours. As a guide to the corpulent it may be said that the fat of meat, butter, cream, stgar and sweets, pastry, puddings, farinaceous articles as rice, sago, tapioca, &c., potatoes, carrots, pars- nips, beetroot, sweet ales, porter, stout, port wine, and all sweet wines should be avoided, or only very sparingly consumed. Wheatcn bread should only be partaken of moderately, and brown bread is to some extent better than white. The gluten biscuits which are prepared for the diabetic may, on account of their com- parative freedom from starch, be advantageously used as a substitute for bread in the treatment of obesity. The articles that may be taken to the extent of satisfying a natural appetite, are lean meat, poultry, game, eggs, green vegetables, succulent fruits, light ■yvines, dry sherry, and spirits. Milk should only be taken sparingly. Holding the position that food does in relation to the operations of life,; the art of dietetics not only bears on the maintenance of health but is capable of being turned to advantageous ac- count as a therapeutic agency ; and it is not too much to say that success in the treatment of disease is oftentimes dependent upon a display of judicious management in regard to food. In the therapeutic application of dietetics the maxim should be held in view that, whilst the particular requirements are secured, there should otherwise be no greater deviation from what is natural than the special circumstances of the case demand. The quantity pf food consimied may require to be regulated as well as its nature. The quantity administered at a time should stand in relation to the power of digesting it; and to properly compensate for a diminished capacity for taking quantity there should be a correspond- ing increase in the frequency of administration. ' 'Little and often ' is the maxim to be followed ujon many occasions, and much will sometimes depend upon the strictness with which it is acted up to ; for, apart from harmonizing with what is wanted, upon the principle that has just been referred to, it meets the defective aptitude that exists in sickness for sustaining any length- ened duration of abstinence from food. In febrile, acute inflammatory, and other con- ditions where, there is a failure of digestive power, the food administered should be such as not to tax the stomach, and should therefore consist .of liquid materials. Solid matter, by remaining undigested— and solids of an animal nature are particularly likely to do so — would act as a source of irritation in thg: stomach, and only serve to aggravate the condition of the pa- tient. The articles under such circumstances to be selected from are beef-t^ea, mutton, veal, or chicken broth, whey, calf s-foot and other kinds of jelly arrowroot and such-like farinaceous articles' barley water, rice mucilage, gum-water, fruit jelly, and the juice of fruits, as of lemons, 864 DIET. oranges, &e., made into drinks. Where a little latitude is allowable, the employment of milk and of eggs in a fluid form may be sanctioned. As cireumstauces permit, an advance may be made to solid substances which do not throw much work on the stomach, as rice, sago, tapioi'a, bread and custard pudding's, and stale bread or toast sopped. Next may be allowed fish, be- ginning with whiting;. As power becomes re- stored, calves' feet, chicken, game, and butcher's meat — mutton to begin with — may be permitted to follow. In oases of ordinary dyspepsia the aim of the physician should be rather directed to raising, by appropriate treatment, the digestive capacity to the level of digesting light but ordinary food, than to reducing the food to an adjustment with a low standard of digestive power. Of butcher's meat, mutton is almost invariably found to be the most suitnble ; chicken and game are allow- able, also white fish (boiled or broiled) particu- larly whiting, sole, flounder, and plaice. Stale bread, dry toast, plain biscuits, floury potatoes, rice, and the various farinaceous articles form the kind of food derived from the vegetable kingdom to be selected. Green and other suc- culent vegetables, it is found, are more apt to create flatulence than other kinds of food, and articles belonging to the cabbage tribe are par- ticularly to be regarded as obnoxious to those who have a tendency to this form of derangement. Much depends in cases of yiea^ digestion upon the state in which the food ' reaches the stomach. Thorough mastication affords great assistance to the performance of digestion', and when the teeth are bad the food should be finely minced, or otherwise minutely divided before being eaten. Regularity in the periods of taking food, tends to promote the orderly working of the digestive organs. An interval of more than fo'ir or fire hours' duration between the meals is to be avoided, as it acts perniciously in several ways. By inducing an exhausted state of the system it diminishes the energy of thfe digestive organs, and whilst having this effect it at the same time calls for the periodical exercise of increased energy, on account of the larger amount of food which must be taken at each meal to compensate for the length of time that is allowed to elapse between them. In cases of ulce* of the stomach, acute gastric catarrh, and vomiting, the food must be selected from that which is nutritious and at the same time taxes least the digestive powers. Milk — and this is often better borne after being boiled — milk and water, or milk and soda water, will frequently be found to be tolerated when other articles excite irritation and are returned. Some- times the milk may be advantageously mixed with isinglass, arrowroot, ground rice, or biscuit powder. In dysentery and other forms of ulcerative disease of the intestine, scrupulous attention must be paid to diet. The food should consist of arti- cles which are known to exert the least stimulant and irritant action on the mucous membrane and muscular coat of the alimentary canal, and those which best meet the demand in question are such as milk, isinglass, and the various fari- naceous products, amongst which rice is pre- eminently valuable. Kext to these come eggs, white fish, white-fleshed poultry, fresh game, and fresh meat. Salted and dried meats are highly objectionable,and fruits arid succulent vegetables, with the exception of a floury potato, should le strictly shunned. See Peitonisbd Food. ■The development of gout is known to be fa- voured by the consumption of a highly nitro- genised diet, especially if conjoined with seden- tary habits. With those who have already experienced symptoms of the disease, and those also who have grounds for apprehending its in- vasion, it is important that an excess of nitro- genous food should be avoided. The diet should be simple, in order that the temptation may ba avoided of eating too much, and should at the same time be adjusted to the mode of life. The * principle to observe is that the higher the degree of inactivity the greater ought to be the pre- ponderance of food derived from the vegetable kingdom. Even of more importance than what is eaten is what is drunk, where the question of gout is concerned, and observation shows that it is not distilled spirits, but the stronger wines and malt liquors, which favour the production of the dis- order. Nothing is more potent than port wine in leading to the production of gout, and a few years' liberal indulgence in it has often been known to be instrumental in bringing on the disease where no family predisposition had ex- isted. Dry sherry and the light wines, as claret, hock, &c., may be drunk, certainly in moderation, with comparatively little or no fear of inducing the disease, although aiiy kind of wine appeal! capable of sometimes acting as the exciting cause of 'a paroxysin where the griuty dispositioft is ateady established. Stout, porter, and tKe stronger ales, especially those that have bej!ome hard from age, rauk next to port wine in their power of predisposing to gout. As regards, the light bitter beers, which are so extensively used at the present time.'the same must be said of them as of the light wines, viz. that with little, if any, disposition to induce the disease, they nevertheless appear capable of sometimes excit- ing its manifestation in a gouty subject. A pure Spirit, as whisky, hoUands, or brandy, diluted with water, often forms the only kind of alcoholic drink that is found to agree with those who are suffering from gout. In Bright's disease with threatening ursemio poisoning it is a point of consideration to diminish as far as practicable the amount of excretory matter to be eliminated by the kidney. The fats and carbo-hydrates throw no work upon th« kidneys. Their products of destruction escape through another channel. Nitrogenous matters, on the other hand, undergo metamorphosis inthe system, and yiuld nitrogen-containing compounds — chiefly Tirea— to escape by the kidneys. In thij way the kidneys become taxed by nitrogenous food, and, to lessen the work demanded of them, reason suggests that the diet should preponderate in food deiived from the vegetable kingdom. In diabetes mcUitus there is a want of assimi- lative power over the saccharine and starchy principles of food. 'Whilst these principles be- come utilized and lost sight of when ingested by a healthy person, in the system of the diaheti9 they fail to become consumed, but pass offundoi DIET. the form of sugar in the urine, giving rise to severity of symptoms in proportion to the amount of sugar escaping. Much may be done towards Buliduing the symptoms of the disease by a pro- perly arranged dietetic scheme, and the principle upon which it requires, to be framed is the exclu- »ion, as far as practicable, both from what is eaten and what is drunk, of articles containing saccha- rine or starchy matters. Observation has shown that the reaction of the urine is susceptible of being influenced by the character of the food. The effect of animal food is to increase the acidity of the secretion, whilst that of vegetable food is to diminish it, and, even it may be, to produce alkalinity. Hence on . persons affected with the lithio acid diathesis benefit is conferred by a plan of diet in which animal food is limited, apd succulent vegetables and fruits, with the light wines, as claret, hock, &c., are freely supplied. Ou the other hand, with the phosphatic diathesis, the converse prin- ciple of action should be adopted. F. W. Pavt. DIGESTIOIT, Disorders of.— The func- tion of digestion is of a physico-chemical nature, being compounded of certain muscular acts, and of certain processes exercised by the digestive fluids on the ingesta. Any interference with tlie due performance, of tlie several components of. the function wiU lead to indigestion, and though it may for con- venience be desirable to consider these disturb- ances separately, it must be remembered that the occurrence of one condition is apt to be quickly associated with another, and hence the forms of dyspepsia as they usually present (;hem- selves are of a complex nature, however simple the primary fault may have been. Nor is it possible to consider irregularities of digestion only from the point of view of the organs im- mediately concerned. Complicated as our or- ganism is, disturbances of other functions will speedily make themselves felt in the one under consideration, and failures in tlie absorption of the digested food, or in its subsequent metabolic changes and elimination, will tell bapk sooner or later on that process which is, strictly speaking, limited to its preparation. Dyspepsia then may be traced to (i.) the food ; (ii.) disturbances of the so-called mechanical processes, viz. the muscu- lar acts, solution, &c. ; or (iii.) imperfections in tbe chemical changes exercised by the digestive Becretionis. I. Impeefectiows of Food.— Imperfections in food, iirliether in quality or quantity, are among the most frequent causes of digestive disorders. A thorough knowledge of the principles of dietetics is essential, th^t the errors may be ^cognised and remedied. Since our digestive capability is limited, it; is obvious that when those limits are overstepped, the domain of disease is entered upon ; and although no very absolute lines may be laid down for universal application, the general rules for quantity and kind are capable of being stated. See Diet, Fven when the food is as it should be, dys- pepsia may be determined by perversions of the appetite; or, on the contrary, such perversions uiay bo due to the same causes which lead to the DIGESTION, DISORDERS OF. 366 functional errors in the digestive organs. See Appetitb. (o) Dificiency of Food. — Except under rare conditions, such as famine, &c., this is not so common a cause of disease as is supposed. We habitually take a larger bulk of food than is demanded, and it is very certun that most active lives are led on an amount of food far below what is ordinarily regarded as being necessary. May it not be that many of the diseases looked upon as non-preventible, more particularly those connected with the excretory organs, are really duo to their overwork in getting rid of the excess of the ingesta ? Of the signs and symptoms of starvation it is not needed here to treat. But there are frequent occasions when, with no deficiency in the total bulk of food taken, there is yet a serious want in one or perhaps more of the needfid alimentary principles, and this is especially liable to occur in the feeding of children. Setting aside those gross cases of cruelty, when infants and the youngest children are fed almost from their birth with bread, broth, or even meat, there are still too often to be met with children whose diet-scale is almost entirely wanting in nitro- genous matter. Fed upon milk and infants' foods, the latter consisting of little more than starchy material, their tissues are ill-formed for the want of projteids, which, during the period of growth, are required in a larger relative proportion. The relationship of rickets to prolonged suckling, with the accompanying de- ficiency in nitrogenous and amyloid food-stuffs, is now generally recognised. The effect of a deficiency of food is a general state of malnutrition, in which any hereditary tendencies to disease that may exist have a more favourable field for development. There is a gradual diminution in the weight of the body, and an imperfect performance of its func- tions, as indicated by muscular weakness, mental lassitude, &c. The deficiency in food l^aken may result not so much from a defective supply of nutriment, as from a disinclination to eat, a common symptom in most diseases, especially in febrile states, self- imposed fasting too frequent or prolonged, the anorexia of . the hysterical temperament, and obstruction to the entrance of food into the stomach from sti^icture of the oesophagus, or the appetite may be impaired by over-indulgence in alcohol or tobacco. (;8) Excess of Food. — There is very little doubt but that more food is daily in the habit of being taken than is actually required to restore the tissue-waste, as ther^ is equally little doubt that much of what is taken is not in the most digestible form. It is open to question whether the appetite would be satisfied by the in- gestion of merely sufBcieut (o balance the waste, particularly if the gross bulk of the food taken were diminished by the removal, as far as pos- sible, of all indigestible matters, leaving little more than the needful alimentary principles. At the same time it must not be forgotten that the appetite is very easily controlled by custom, and determination can in time overcome a vicious habit. An habitual excess of food, at least in this DIGESTION, DISOEDEES OF. coontiTi usually ens in the disproportionate amonnt of nitrogenous matter it contains. Remembering the relatwely small quantity of this principle that is essential, and in what a number of the ordinary articles of diet it is contained, this statement will be the more readily accepted. Now, since all the proteid principles require, to fit them for absorption into the blood, a considerable amount of chemical alteration, and, physiologically speaKng, there is good resison to believe that the eabsequent me- tabolic changes of these matters, when absorbed, are more complex than those undergone by fats and amyloids, it would follow that those organs concerned in effecting these changes are yery prone to suffer from overwork and :ta sequelae. Again, it appears very probable that when the amount of nitrogenous food taken is much in excess of what is required, it under- goes certain oxidation-changes in the blood without becoming tissue previously, and an enormous ingestion of albuminoid matter is fol- lowed by its elimination very much as it is taken. Now, many of the compounds resulting from the oxidation of nitrogenous matter are liable to become positive poisons in the economy when existing in excess, and the proper elimina- tion of such materials is specially provided for by such organs as the kidneys and skin. The frequency with which these organs become the seat of disease may at least indicate the proba- bility of errors of diet being an important factor in determining the morbid changes, especially as considerable relief is often the result of a restriction of nitrogenous food. There can be little doubt but that the large group of diseases associated with failure in elimination of nitro- genous waste has for a prominent cause an habitual excess of nitrogenous food. The results of an excessive ingestion of food are as numerous as they are diverse. In many cases there does not seem to be either impair- ment of health or shortening of life. In some obesity and in others leanness ensues. In a large majority of individuals whose food is much in excess of their wants, particularly if the exercise taken be but little, there are vari- able symptoms of indigestion, such as a geneYal feeling of lassitude and want of energy, both muscular and mental, a liability to headaches chiefly frontal, constijiation-, or more rarely diar- rhcea, high-coloured urine depositing abundance of urates, a general disposition to sleep, various skin-eniptions, particularly acne, and not in- frequently a feeble heart's action from com- mencing fatty degeneration of its substance. Any or all of' these symptoms may exist, and may be more or less completely relieved by a restricted diet. It is impossible to lay down any exact rules for thfe quantity of food that should be daily consumed j though it is desirable to remember that the tendency is to take too much, at the same time' that age, season of year, ■ind_ occupation are all circumstances deter- mining variations both in quantity and kind. (7). Improper Food. — Setting aside those ex- treme_ cases of perverted appetite occasionally •een in the hysterical condition, there yet re- mains a very constant violation of the dietetic proprieties. These errors may be classed under the following heads: — 1. Substances which are indigestible j either essentially so, or from im- perfect preparation (cooking, &c.) 2. Sub- stances fl'hich, though digestible, are innntri- tious or even poisonous. In the first group toe included such bodies as the pips and sec^as well as the skins and rinds of fruits, the husks of corn and bran, the stalks and' ' fibres of leaves, and gristle, elastic tissue, and hairs in animal food. For the reducing of these to a fluid and diflusible condition no chemical ar. rangement exists in the human organism, and they are thrown off very much in tlie same state as they are swallowed; Many articles of diet depend in great part for their digestibility on their proper preparation by division, cooking, &c. Thus most vegetables when taken in the raw state are but imperfectly digested, and such nutritious food as potatoes becomes when un- cooked positively harmful. The apparent*Taliio of raw green vegetables, as lettuce, 'endive, cress, &c., would seem to depend on the pecu- liar condition of their mineral constituents, rather than on the vegetable tissues. Such substances as the above-mentioned are apt to produce perversions of digestion in virtno of the mechanical irritation they give rise to, indicated by more or less pain of k griping character (colic), and frequently accompanied by diarrhoea. ' The ' constant ingestion of tlie mora formidable may even set up a gastro-enteritis, acute or chronic. Occasionally articles of food, such as brown bread, oatmeal porridge, &c., are taken for the very aperient action they induce, owing to the irritating nature of the indigestible husks they contain. Symptoms of' acute dys- pepsia very frequently follow the taking of meat foods enveloped in greasy sauces, since the fat, being undigested in the stoinach, prevents the action of the gastric juice on the proteid matter, which then passes on into the intestines, setting up irritation lik6 any other indigestible substance. The'most interesting among those ar- ticles of diet which, though easily digested may be poisonous, are those "producing their effects only on certain individuals. Such, for example, are certain mushrooms, shell-fish, or indeed any fish. Eemarkable eases are authentically re- corded of serious and even fatal results follo¥- iilg their ingestion; The symptonlS may be those of an acute gastro-enteritis, or, as is very fre- queutly the case, an urfibaria is the result, with or without swelling of the eyes and throat Severe nervous prostration has been met with occasionally. Be it understood that other people have partaken of the same diet with no i!l results. The writer is acquainted -with a gentle • man who for many years was unable to remain in the room when fish of any kind was on the table; its presence inducing severe vomiting, ahdo- mintil pain, ■ and geiferal illness ; aiid although the ' effects are now but slight from the mere smell of such food, very marked symptoms fol- low on partaking bf any. The most digestible and nutritious articles of food may determine indigestion when taken too hot or too cold. Finally must be included those substances which accidentally find their way into the ali- mentary canal with the food, as entozoa, ergot of rye; such foreign bodies as pins, needles. DIGESTION. DISOEDEES OF. 367 Mas, buttons, &c. ; or lead and other metallic poisons off the hands of workers in these poisons ; all of which give rise to definite and for the most part characteristic symptoms. II. Irbbodlabities of the Mechanism op Digestion.— The motor factors of the digestive process depend for their diie and normal per- formance on the integrity of the muscular tissue, the nerve-centres, and the connecting nerves. The several stages of the entire process are mastica- tion, deglutition, the churning movements of the stomach, the peristaltic action of the intestines, and defsecation. Each of these is liable to im- pairment, in the direction of excess (spasm), or of deficiency (paralysis), due either to lesions of the nerve-centres whence the motor stimuli ema- nate, of the nerve-fibres by which these stimuli are conveyed, or of the muscular tissue by which the movements are performed. Not un- frequently more than one of these tissues may be at fault Lastly, obstructions to the movements may be caused by tumours, cicatrices, &c. Irregu- larities of mastication, deglutition, and defseca- tion are fully considered elsewhere. 1. Paralysis. — Arrest of the peristaltic action of the gullet, stomach, or intestines, is un- doubtedly often associated with diseased con- ditions of the central nervous organs, but the exact connection is far from being satisfactorily known. Those lesions which interfere with the action of the vagus nerve, and remove its accele- rating influence over the peristaltic movements, have been regarded as most likely to bring about this condition. The nervous exhaustion induced by long fasting, continued vomiting, hysteria; and such diseases as typhus and puerperal fever, hare been noticed as removing the influence of the pneumogastric. Over-ibrainwork, with the attendant altered conditions of cerebral vascu- larity, have been found to be accompanied with symptoms indicating loss of power of the mus- cular coat of the bowel; possibly in this case also the influence is conveyed by the vagus. Paralysis of the stomach and intestines is a frequent result of affection of these organs themselves. Inflammation of the peritoneal or mucous coats, with the subsequent infiltration of the muscular coat with the inflammatory products, materially diminishes the power of the contractile tissue. Degeneration of the organs, particularly the lardnoeous variety, which com- mencing in the mucous subsequently invades the muscular coat, obviously interferes with the movements. The movements of the alimentary canal may be considerably diminished by the administration of certain drugs, such as opium. The results of these various paralytic affec- tions are in most cases sufficiently apparent. The : palsied lips and cheeks and tongue tell their own tale by the half-opened ' mouth, the dribbling saliva, and the cheeks distended with food which cannot be kept between the teeth. When the fauces and pharynx are affected, the painfiil efforts at swallowing, the rejection of food through the nose, and the passage of food into the larynx are signs not to be mistaken. Paralysis of the stomach and intestines is mainly recognised by the constipation from inability of the canal to propel its contents, and by the dis- tension with gases, &c., which ensues ; whilst the involuntary passing of the fiBCes indicates para- lysis of the sphincter ani. 2, Spasm. — Spasmodic affections of the ali- menta,ry canal are characterised by an increased motor activity dependent on many causes for its production. However diverse such causes may be, they ultimately resolve themselves either into an increased irritability of the nervous and contractile tissues, or into some unusual or excessive stimulation, arising ab extrd, and so producing its motor result in a reflex manner, or originating automatically in the cells of the motor ganglia. Spasms affecting thai organs under consideration are determined both by cen- tral and peripheral causes, and occasionally by affections of the nerves independently of the nerve-centres. They are mainly of the tonic variety, and are usually accompanied by pain. It is clear that with the muscular tissue of the alimentary canal arranged as it is, when a con- ditibn of spasm exists obstruction to the passage of the contents of the canal will take place, inpro- portion to the extent and duration of the cramp. Spasm of the stomach and intestines is almost invariably accompanied by pain ; and it is for that symptom,: rather than for any obstruction; that the condition comes under notice. The pain at the back, so frequently complained of in anaemia, is believed to be mainly due to gastric spasm; and in certain other constitutional states, such as gout, it may be a prominent symptom. Occasionally it is due to uterine or ovarian dis- turbances, acting in a reflex manner. Spasm of the pylorus isi of theoretic rather than practical interest. Intestinal cramp (colic, tormina, &c.) is of 'frequent occurrence as the result of ir- ritating' ingesta,. lead-poisoning, hernia, intus- susception, and ulceration in malignant disease. These spasmodic affections may also result from diseases of the spinal cord. How far over-action of the involuntary muscular tissue of the ali- mentary tract may exist without pain is , un^ certain ; since we are ordinarily unconscious of the 'peristalsis, it is probable that any exaggera- tion of action is painful. The normal tenacity of the sphinctpr ani may give place to painful spasm, a condition which is very apt to complicate fissure and ulcer of the anus, : ,' Hyperkinesia, or exalted motor activity of the muscular tissue of the digestive organs, may be a part of the general state induced by such poisons as strychnine, 3. The due performance of the mechanism of digestion may be interfered with'by alterations in the condition of the alimentary canal caused by various kinds of obstruction or dilatation. Thus deglutition may be rendered difficult or even impossible by a swollen tongue or tonsils,- post- plmryngeal abscess, tumours of the cesophagus or larynx, or new growths! situated at the cardiac aperture of the stomach. The various obstructive diseases of the pylorus and intestines will ob- viously interfere with the proper passage of the contents, and in those dilatations of the canal, which are liable to develop above a stricture, the food accumulates and is delayed i n its. passage. The adhesion of coils of the bowels to each other or to adJEicent structurea is a further source of .imperfect movement. 368 Lastly, the sntdivision of the solid food,_so necessary for the effective action of the digestive juices, is only imperfectly performed when the teeth are deficient in number or are carious, and to this cause a large proportion of cases of dys- pepsia may be fairly assigned. - So marked a perversion of the mechanism of digestion as vomiting is more fitly described by itself, though it is a very frequent symptom of indigestion. III. Impekfeotions in the Chemioai, Changes. — Our knowledge of the normal chemistry of digestion, much as it has advanced of late, is still very far frnm complete, and, in face of our ignorance, but little can be said of the conditions existing in disease. Yet there are certainly no departures from the healthy working of the body so common as are those associated with the digestionof the food. The various secretions, whose ofSce it is to convert into a fiuid and diffusible form those alimentary principles which without such prepa- ration cannot be absorbed, are formed from the blood by the salivary, geistric, pancreatic, he- patic, and intestinal glands. It is clear that, for these juices to be secreted in proper quantity or of proper composition, the blood no less than the secreting cells must be in a healthy con- dition. If the circulating fluid be laden with imperfectly secreted products of tissue-change, or if it be charged with poison, of whatever ori- gin, it is not to be expected that a normal secre- tion is to be obtained from it ; whilst on the other hand a degenerated secreting epithelium is unable to perform a function intimately de- pendent on the integrity of its protoplasm. Of ne- cessity these two factors — blood and cells — ^react OQ one another ; any flaw in the one is recipro- cated by the other, and thus becomes intensified by mutual interdependence. Experiment leads u£ to ascribe the efficacy of these juices in the changes they effect to the existence in them of certain so-called ferments, whilst the result they bring about is mainly one of hydration. How far the various mineral constituents of the se- cretions aid in the process is uncertain, but at least their presence cannot be dispensed with. In this way, the insoluble starches of our food are converted by the saliva, the pancreatic, and pos- sibly the intestinal juices, into soluble and diffu- sible sugars ; the various proteids are rendered capable of absorption into the blood, by the gastric and pancreatic juices, and perhaps also the succus entericus, being changed into bodies known as peptones. The fats are prepared for absorption by the bile and pancreatic juice, by being in part reduced to a sufficiently minute state of subdivision (emulsion) to permit of their passage through the tissue-interstices, and partly by being chemically altered into soaps. How- ever closely we may imitate the separate actions of these fluids in our test-tubes and laboratories, the conditions are undoubtedly much more com- plicated in the alimentary canal, where so many sets of changes are going on, and so many sets of prodncts are formed. Despite our imperfect knowledge we can yet suggest in outline the causes of the abnormal chemical changes, however far we may bo from ascribing with accuracy to their proper con- DIGESTION, DlSOEDEES OF. ditions the multiform symptoms which such changes undoubtedly give rise to. • Primarily the secretions may be deficient in quantity, improper in quality, or both, and the following are some of the causes leading to such results : — 1. Perverted nervous influence. The direct control of the nervous system over the quantity and quality of the secretions is well known, and there is every reason to suppose that the tem- porary arrest of the salivary fluid so frequently accompanying any severe mental disturbance, such as fright, represents, but in a transitory manner, a disturbance that may be more lasting and more serious in lesions of the central nervous organs. The imperfect digesti"n, as indicated by the tongne, breath, excreta, &e., so common in brain-diseases, even when all precautions are taken, is only to be explained in this way. There in nothing improbable in suggesting that a cause which may in one case bring about an arrest of secretion, may, if prolonged, indiice a perversion of the same. 2. Abnormal blood-supply. A deficiency in blood being almost always associated with an alteration in its quality, it is easy to see why in a state of anaemia the digestive ^nction suffers, whilst the more it fails the more will the ansemia increase. Hence the care needed both in diet and drugs for such patients. In some cases the blood may be wanting in those constituents which go to form the secretions. Occasionally persons are met with who, from habit or inclination, take a quantity of fluid far below the ordinarily sup- posed requirements. In such the secretions would seem to be insufficient in quantity to do their work, and an irritable form of dyspepsia, caused by the presence of imperfectly digested food, is the result. Or again, certain symptoms may point to a deflciency in such special elements of the secretions as hydrochloric acid, bicarbonate of potash, &c., and considerable relief or a cure may follow the administration of these substances, or it may be the ferments themselves are want- ing, and pepsin or pancreatin are indicated. Itis not asserted that our knowledge at present leads us to recognise with accuracy the exact nature of the deficiency in the secretions, but in view of the relief that is afforded by acting on the lines laid down by physiology, it is only reasonable to expect that in time the expres-ions of disease may be more exactly defined, and so a rational basis constituted for treatment. After prolonged fast- ing the gastric juice is secreted in but small amount, and under ordinary conditions that which is first poured into the stomach is far less active than that later formed. In other words the quality of the secretion improves as the food, which supplies its ingredients, is absorbed. Hence the occasional advantage of prefeciug » meal with a small quantity of some piquant food. From a blood laden with impurities, whether of ingesta or non-eliminated products of tissue- waste or specific poisons, healthy secretions are not to be expected, even did the secreting agents remain healthy. Thus the dyspeptic symptoms associated with alcoholism, pout, and the acute specific diseases are to be explained. - 3. It has already been said that it is practi- cally impossible to disassociate altered blood DIGESTION, DISORDERS OF. SGd states from perverted tisBue-structure ; and if the nutritive fluid of the hody be diseased, the elements nourished by it may be expected to be imperfect. Some of these departures from the normal are not recognised, partly from the dif- ficulty of observing them, and still more from ignorance of the exact standard of healthy structure in tissues which are perpetually chang- ing, even within healthy limits. Other changes, however, we can see ; and the degenerate cells of an amyloid liver, or the desquamating epithelia of the gastric follicles in scarlatina, can no more be expected to eliminate healthy secretions, than can a fatty heart to contract properly. A further source of disturbance in the chemical changes in digestion is to be found in the fermen- tative and putrefactive processes set up in the contents of the alimentary canal. How tar such processes are normal is uncertain ; but occasion- ally the contents of the stomacli are vomited in a state of active fermentation, and teeming with living organisms. All ill-smelling gases and excreta may be, indeed, indicative of the progress of putrefaction lower down in the canal. That gastric juice and bile will normally arrest putre- faction, whilst pancreatic juice favours it, is well known, and hence we are led to infer some altera- tion in the secretions when signs of decompo- sition appear. Symptoms of Dyspepsia. — The almost num- berless symptoms which indicate the perverted functions above described, may be considered as those associated with the special organ at fault; and those manifested by the system generally. (a) Among the first group are perverted sen- iations. Ordinarily we are unconscious of the process of digestion, but in disease the function may be accompanied by alterations of sensation, varying from a mere sense of weight and discom- fort in the abdomen to the severe spasmodic pain of colic. Thcr ingestion of food may be followed by a feeling of abnormal repletion, or of emp- tiness with craving for food ; or there may be heartburn, an ill-defined sense of burning felt in the epigastrium or over the chest, or extending to the throat, or positive pain or tenderness felt over some tolerably definite area. Sensations as of excessive movements of the bowels, of sinking, or of tightness across tlie abdomen, are of fre- quent occurrence. (i) Affections of the appetite as results of indigestion have already been referred to. ((!) The various movements of the alimentary canaimay be interfered with. They may bedelayed or evenarrested, as occurs in constipation ; or exces- sive, with consequent diarrhoea. Vomiting, either directly or at a variable interval after taking food, is a common symptom, with or without pain ; very frequently the vomiting relieves the unpleasant feelings that may be present. Eructa- tions of gas, hiccough, and the frequent passing of much flatus occur in many cases, (d) The vomited matters vary considerably. The food may be ejected very much as it has been swallowed, or it may be in a state of active fermentation and turning into ferments. A symptom very often complained of is the eructa- tation into the mouth of a fluid, which is fre- quently acrid and bitter, at other times tasteless (pyrosis) : it is probably altered gastric secretion. 24 Blood may be vomited (hcematemesis) ; of passed per rectum (meleena). Tha breath Kay b* foul. (s) The state of the tongue, its colour, size, and general appearance as to iva, dryness, smoothness, and prominence of p&pUI%, are often indicative of the condition of Ibn Btomach and intestines. (f) Such sympathetio sympfoma as headache, pain in the back or in the right shoulder, dizzi- ness, specks in the field of vision, palpitation, or irregular action of tho heart, cough, disordered urine, &c., indicate the relation existing between the digestive organs and the body generally. ig) Tho more grneral symptoms that are foimd associated with disordered digestion may be those of pyrexia, when an acute inflammatory condition of the digestive organs is tho cause of the disturbance. Since, however, the affection* are more usually of a chronic nature, a gen'>rp.l wasting and emaciation from insufiBcient novxhh.- ment is likely to ensue. In such a state tho pa- tient is prone to develop any diathesis to -ffhioh he may be liable, such as the neurotic, car.cerous, &c. The peculiar sallow, muddy-looking skin, often slightly tinged with bile and markedly ansemic, is characteristic of many cases of chronic indigestion; a poorly nourished body can ill stand the slightest fatigue, though such patients are often apt to brighten up towards evening, and, indeed as a rule dyspeptic patients are worse in the morning. All conditions of disordered tem- perament are met with, from a confirmed apathy and hypochondriasis to a persistent and increas- ing irritability. Whilst some patients are always drowsy, others complain of a distressing insomnia, or a troubled and dreamy sleep. Tbeatmekt. — Oftener perhaps than may be supposed, the cause of the disturbance of diges- tion is a removable one ; in any case it must be well searched for, and arrested if possible. A care- fully regulated diet, both as reganis ordinary food and drinks and special idiosyncrasies, is in all cases the most important, and the means from which much good is to be expected. Exercise, bathing, ' occupation both mental and bodily, change of scene and air, will require attentive consideration. Much, however, may be done with the aid of drugs. Sufficient indications often exist to justify prescribing, with perfect confi- dence, such tonics as vegetable bitters, quinine, strychnine, and iron; such constituents of the digestive juices as mineral acids, pepsin, and alkalies; or drugs whose value appears mainly to consist in tbeir sedative action, as hydro- cyanic acid, bismuth, opium, and belladoiina. Arsenic, zinc, silver, creasote, charcoal, valerian, the hypo-sulphites, and the carminatives generally, are a few among the long list whose value is assured in difiTerent cases of dyspepsia. It is important to attend to the condition of the bowels ; as well as to the hepatic functions. See Stomach, Diseases of. CosoLTJsioH. — In the foregoing remarks no attempt has been made to enter into a detailed description of the various symptoms of disordered digestion, or to do more than indicate very gene- rally the treatment to be followed. Such subjects are left to the diseases treated of in their respec- tive articles. Nor has it been thought desirable in this article to treat the subject from the ill- 370 DIGESTION, DISOJRDEES CF. defined point of view of ' varieties of dyspepsia.' Bather it has been sought to bring the matter of indigestion -within the limits of an anato- jnico-physiological basis, since it is only on such lines that the protean symptoms of dys- pepsia can be accurately defined. At the same time whilst for clearness the various causes have been made to assume a somewhat tabular form, it is not intended that the interdependence of these states should be overlooked, or that one only of the causes mentioned is at work in any giv^ case. The complexity and harmony of our functions alike forbid such a mistake being made. Yet for that mental analysis which the formation of a diagnosis presupposes, some such scheme as the foregoing is essential, no less than for the adoption of a rational treatment. W. H. AlXCHIN. DIGESTIVE OBGAWS, Diseases of the. — The organs comprised in the digestive system have for their function the preparation of the solid and fluid ingesta of the body, so as to fit them for absorption into the blood. Some of the food requires little or even no such prepara- tion ; some needs considerable treatment, both physical and chemical. To effect this object it would appear to follow that there should be some receptacle or series of receptacles into which the food may readily be taken, and from which the worthless residue may escape, provided with muscular structures to ensure a movement of its contents. It would further follow that there should be certain organs communicating with the foregoing, whose function it should be to prepare those materials necessary to effect the required chemical changes in the food; and, lastly, that some arrangement should exist to permit of the ready absorption of the digestive materials. Such requirements we find supplied in the alimentary canal, with its terminal apertures, and its continuous muscular coat Sio arranged as to main tain a progressive advance of the contained food, though with varying degrees of speed — ^for some lengths, as through the gullet, without any arrest ; in others, as in the stomach, with con- siderable delay. Into this canal open numerous glands (mucous, salivary, gastric, intestinal, hepatic, and pancreatic), the secretions of which play each their special part in the conversion of the food to a fluid and diflusible state. From an anatomical, and indeed a genetic point of view, these glands may be regarded as more or less complicated diverticula of the mucous surface. In order that the food when so treated may gain a ready entrance into the blood, the surface of the canal in contact with the digest- ing food — ^mucous membrane — offers various modifications — villi, &c. — to facilitate the process of absorption. Lastly, in beings so complex in Bcructure as man, there is need for some control- ling influence to bring the operation of this system of organs into harmony with the actions of other and interdependent systems. Such power of co-ordination is exercised vid the nervous system, sympathetic and cerebro-spinal. By the expression 'diseases of the digestive organs' is meant, departures from the normal structure of the tissues of which these organs ore composed. DIGESTIVE OEGANS, DISEASES OF. The I constructive tissues of the alimentaiy organs are : — 1. The Epithelial ; 2. The Connec- tive ; 3. The Muscular ; and, 4, a compound tex- ture— the Vascular. Eadh of these is subject to its own perversions, either alone or in common with others. JEmoiaOY. — If we consider diseases to be altered functions dependent on altered structure, the latter being determined by some perversion in the normal stimuli to nutrition, either heredi- tary or acquired, we shall at once recognise that the opportunities for abnormal stimulation in the case of the digestive organs are most numerous. Communicating with the external world and continuously sulgect to the admission of foreign matter, we have in the character of the ingesta abundant sources of disease. Toxic agents, living and dead, find ready entrance, and excesses in quantity of food, no less than imperfection in its quality, alike serve to produce those depar- tures from the normal structure on which per- versions of function depend. Furthermore, the tissues of the alimentary viscera are, equally with those of the body gener- ally,subject to those more obscure hereditary in- fiuences which determine irregularities in stmc- ture and their sequence. And, finally, arrests in development of organs, not unfrequent in those under consideration, complete the list of possible diseases to which the alimentary system is liable. Nor is this system independent of morbid con- ditions affecting other organs: So complicated as is the human body it is impossible that disease should forlongbe limited to one region. Sooner or later the functions which are now reacting the one upon the other, to constitute the harmo- nious working of healthy life, will feel the effects of the one that is out of gear, and will respond each in its own manner to the abnormal condi- tion. A disease primarily located in the nervous system will produce an effect in the working of the nutritive functions, none the less real because the exact lesion cannot as yet be deter- mined. Failures in elimination of the products of tissue-waste from structural diseases of tie excretory glands, must tell back on the organs concerned in the preparation and elaboration of the ingesta, and such conditions constitute a fre- quent cause of disorders of digestion. ' The causes may be thus tabulated : — ' A. Hereditary, 1. Arrests in development of tissues and organs. 2. Abnormal nutritive stimuli, determining new growths, &o. IS. Acquired. 1. Poisons, 2. Imperfections in quantity or quality of normal ingesta. 3. Failure of excretory functions with con- sequent circulation of an impure blood, and malnutrition of tissues. 4. Trophic disturbances acting vU the nervous system. 5. Traumatic. Classification or Diseases. — ^Thereis scarcely any form of diseased structure that is notto be met with in the tissues comprising the digestive organs. Since almost every variety of texture is DIGESTIVE ORGANS, DISEASES OE THE. 37i found in them, and there is so extensive a liability io the causes of disease, this result is only to bo expected. I. .AfCeotious of the Vascular State. — Regarded collectively, the organs of digestion present several paints in respect' to their blood- supply worthy of remark. First, the arrange- ment of the vessels is such as to ensure a very extensive, and at the same time, very direct supply. The arteries to those alimentary organs situate in the abdomen are almost all primary branches of the aorta, and this, together 'with the numerous and free anastomosis between them, reduces to a minimum the chance of failure in circulation. Secondly i the blood from the same area is all collected into one large vein, the portal, and after circulating through the liver is carried by one — the hepatic— directly into the inferior vena cava close to the right auricle. Such an arrangement, whilst perhaps facilitating the direct return of blood, offers a double chance — viz., in the liver and in the heart — of producing a very general state of congestion of the alimentary tissue. Thirdly, tihe existence of such an organ as the spleen, which by its position and structure allows of great variation in the amount of blood it contains, will considerably alfect the extent of vascularity of the digestive organs. Our know'- ledge of the conditions determining the variations in splenic blood-capacity is most imperfect, beyond the fact of the constant enlargement which the organ undergoes after a meal and its subsequent contraction after a few hours, the enlargement being due in great part to increase in the amount of blood contained in it. And, lastly, the alimentary organs probably undergo, witlun normal physiological limits, a wider varia- tion in amount of blood than does any other system. 1. St/peramia is an excess of blood in the arterial side of the capillaries. How far a de- termination of blood to the alimentary canal may exist, unaccompanied by any change in the tissues, is a matter of doubt. In the normal process of digestion this condition obtains, but with it there is an alteration in the glandular epithelia, if in no other tissue-elements. It is conceivable, however, that a vaso-motor paralysis with consequent fluxion may occur, and such may be the case in certain mental states, as indicated by diarrhoea. The majority of circumstances that produce hypersemia do not stop at that point, but bring about a state of catarrh and in- flammation, in which the epithelial and connec- tive tissues are also engaged^ Exposure to cold and extensive superficial burns probably produce their well-known results of intestinal catarrh in this manner. Aniong the digestive glands, the liver un- doubtedly manifests states of simple hypersemia withoutanyappreoiableohangesin the parenchyma of the tissues. Excessive feeding, irritants such as spices and alcohol, hot climates and malaria, have all been recognised as producing temporary enlargements of the liver from vastiular engorge- ment, although without doubt these causes if continued lead to structural aflFections. 2. Congestion, or an excess of blood primarily in the venous side of the capillaries, brought about by some impediment to the return of the blood in the veins, has little or no analogy with any normal physiological action. As a condition of disease it is more important and far more common than the preceding. The two chief causes leading to its occurrence are — (A) Obstruction through the portal circula- tion in the liver, either by compression of the portal capillaries by cirrhosis, &c. , or pressure in the portal trunk by enlarged glands, tumours, &o. ; (B) as part of a general congestion due to obstruction at the right side of the heart from tricuspid dilatation. Due to the very direct com- munication of the veins of the chylopoi'etio viscera and the right auricle, these organs are among the first to experience the effects of the cardiac obstruction. Congestion of the alimen- tary canal and glands, when due to either of these causes, is in the main progressive in its nature, though occasionally liable to temporary relief from treatment. Extreme conditions of vascularity, especially if associated with any haemorrhage into the sub-epithelial tissue, present post-mortem ap- pearances often mistaken for irritant poisons. 3. Beaults of Increased Vascalarity. — (a) Hemorrhage. Over-fulness of the capillaries, from whatever cause, is liable to lead to extrava- sation of blood, either by diapadesis of the cor- puscles and transfusion of the fluid part of the blood, or from actual rupture of the vessels. It is much more common and far more extensive in venous congestion than in arterial hyperaemia. It must not be too readily assumed post mortem that either of these conditions alone is the cause of the haemorrhage, since minute ulcers of the mucous membrane communicating with main vessels have been met with. Dependent on the course and situation, the effused.blood may vary in colour from bright red to a coffee-ground appearance. Haemorrhage due to altered states of the blood is of frequent occurrence in pur- pura, scurvy, &o. (/3) (Edema. An over-dis- tension of the vessels, especially of the veins, if it be at all persistent, is invariably aocompainied by an effusion of serum into the substance of the viscera themselves and into the alimentary canal, in the latter case producing diarrhoea. (7) Tissues the Seat of a chronic congestion in time undergo certain structural changes as the result of their impaired nutrition, which are characterised by the presence of an excessive amount of connective tissue, containing fewer protoplasmic elements than normal, and exhibit- ing a niarked tendency to contract. The fibroid substitution may occur through6ut the entire digestive system, but is particularly noticeable in the stomach, intestines, liver, and pancreas. 4. Anemia. — The alimentary viscera, in com- mon with the rest of the body, may share in a general bloodlessness due to excessive loss or extreme malnutrition from wasting disease, &c. A deficiency of blood limited to these organs is not clinically met with. 5. Infarctions. —As compared with the brain, spleen, and kidneys, the organs of the alimentary system would appear to be less prone to suffer from emboli and thrombi, or at all events from the effects of their conditions. A partial ex- ception to this general statement must be made in the case of the liver, which is a frequent seat 372 DIGESTIVE ORGANS, DISEASES OF THE. of abscess determined by the arrest in the portal capillaries of septic particles taken up by the portal radicals in dysentery, &e. Emboli, as a cause of gastric ulcer, are probably not so com- mon as has been supposed by Virohow, II. Structural Affections. — 1. Inflammation. This term is applied to express those changes ■which take place in the nutrition of a tissue subsequent to the application of some abnormal stimulus which shall not have been sufficiently powerful to produce destruction. The changes in the structural elements of the textures result in the production of some material which is unlike the normal constituents of the part affected, and also in certain destructive pheno- mena. One or other of these aspects may pre- dominate, as in suppuration and abscess or ulcer- ation, &c. Certain variations present themselves in the nature of the new-formed material, and also in the general course of the process, constituting forms of inflammation, as simple, diphtheritic, phlegmonous, aphthous, &c. In vascular tissues there are in addition to the tissue- changes certain alterations in the circulation in the affected region, commencing with hypersemia and leading to a variable amount of stasis. Inflammation as it affects the alimentary tract oflfers no exception to this description. The transition, so far as anatomical appearances are concerned, from the normal state of activity of the organs, with their increased vascularity and cloudy appearance of the epithelial cells, to that of simple inflammation or catarrh, is but a step marked by no abrupt line. The entire canal, with the gland-ducts opening into it, may be the seat of various forms of inflanunation, some regions being rather more prone than others, as the fauces, stomach, small intestine, and bile- ducts. It is rare in inflammatic)n of the canal for the miiscular tissue to share in the process, which is practically limited to the epithelial and sub- epithelial connective 1;issue, and a similar condi- tion exists in regard to the ducts of the various glands. It is a noticeable fact that the epithelia of the canal are but little prone to manifest that general suppurative form of inflammation accom- panied by a large production of pus from the general surface, such as is so commonly seen in the bronchial, nasal, vaginal, and other mucous membranes. In inflammation of the various glands it would appear that next to the ducts the connective-tissue stroma is mainly the tissue affected, leading to a proliferation of the corpuscles and ultimate formation of a less protoplasmic form of fi,brous tissue. -4.mong the chief results of inflammation are : — (o) Jbsoess.—^TLinn may occur in any part of the submucous tissue, in the so-called phleg- monous and pysemic inflaramation, but is of most conunon occurrence in the tonsils and in the liver, often in the latter situation the result of inflammation determined by absorption into the mesenteric veins of septic particles from dysen- teric ulceration. {P) Ulceration. — The mucous membrane of the alimentary canal is particularly liable to this morbid process. Some preference is exhi- bited by flie different forms of ulcer for certain regions of the canal, and a difference exists in the tendency to perforate the entire thickness of the tube, those of shorter duration fre- quently producing this result, whilst the chronic ulcers are usually accompanied by a slow formap tion of indurated connective tissue, which pro- ceeds paripaaav, with the destructive process, and is especially likely to institute adhesions between the canal and adjacent organs. Ulcers are met with in the salivary, hepatic, and pancreatic ducts, very frequently as a sequence of inflanuuatiou determined by the passage of calculi. The ulcers which are usually acute in their course are: — 1. Simple. 2. Aphthous. Tlieso forms, though they may occur in any part of the mucous membrane, are far more commonly situated in the gums, cheeks, tongue and palate, 3. Acute specific ulcerations, as diphtheritic and scarlatinal, mainly affecting the fauces ; or typhoid, limited to the jejunum and ileum, and originating in the solitary and agminated glands. 4. Dysenteric. The ulcers that are commonly chronic- in their course are : — 1. Gastric. 2. Tubercular, which may occur in any part of the canal, but are usually limited to the same situation as the typhoid. 3. Syphilitic, most common in the mouth, fauces, and rectum. 4. Cancerous. 9. JDysenteric. Ulcers, the result of injury or of corrosive poisons, may be either acute or chronic. The latter are rarely met with below the stomach. ' (7) Sloughing and Gangrene, — The inflamma- tory state may be so intense as to lead to molar, death of the area affected, with the produc- tion of slough. This often follows scarlatinal inflammation of the fauces, and the surface of the large intestine in dysentery is frequently covered by large and numerous sloughs. Gangrene is almost entirely limited to the mouth in children, when it produces the condi- tion termed noma. The cheeks are usually affected first, the process rapidly involving the gums, jaws, &c. The cause is very obscuiie. Post-mortem softening and destruction of the stomach and intestines is frequently met with, and is due to an actual digestion of the viscera by the gastric juice, which, thus escaping from the stomach, may cause destruction of adjacent organs. It is usually met with when deathias occurred during the process of gastric digestion, and is more common in infants, possibly from the greater acidity of the products of digestion (lactic acid). 2. Hypertrophy. — ^A general overgrowth of the normal tissues of the digestive organs is prac- tically unknown. Certain parts may manifest this condition, notably the muscular tissue of parts of the canal above an obstruction. The liver is described as being occasionally hjper trophied in certain cases of diabetes. 3. Atrophy. — The alimentary organs may share in the general atrophy and wasting of old age or inanition. This condition is apt to follow the disease of certain parts, as is seen in the thinning and shrinking of the stomach and intes- tines beyond an obstruction or an artificial amis. Pressure on the organs, as by tight-lacing, &c>i may lead to the same result. 4. Degenerations. — Those morbid processes to which the term degeneration is applied, and DIGESTIVE ORGANS, DISEASES OF. which essentially consist in the conversion of the tissues into materials of a less complei chemical composition thannormal, associated with a dimi- nished vital activity, may affect any oral! of the structural elements of -which tte digestive organs are composed. Albuminoid infiltration or doudy sTvelling is the invariable accompaniment of inflammation of the epithelial and muscular tissues. Fatty degeneration is a further result of inflammation, with caseation and occasional calcification. Although not the commonest organs to be bo affected, yet not infrequently the intestine and stomach are the seat of the so-called amyloid or lardaceous degeneration, and not always limited to the vessels, but affect- ing the epithelial, fibrous, and muscular coats, rhe liver is especially liable to undergo degene- ration, both fatty and albuminoid. Deposition cf pigment may be found in the deeper epithelial strata of the mouth in Addison's disease, and in the liver in certain cases of intermittent fevers. 5. Changes in the secretions of the various glands may result in the production of calculi — salivary, pancreatic, or biliary. 6. New Growths. — There is scarcely any Icnown form of neoplasm which may not be found in some region or another of the alimentary tract. The new growths limited to the epithelial coat, or commencing in it, are condylomata, papillomata, encephaloid, and scirrhus. In the fibrous tissue occur sarcoma, filrpma, myeloid, adenoid, gumma, enchondroma, and lipoma. In addition there may be polypi, or tumours of the mucous membrane ; myxoma ; muscular tissue tumour ; cysts ; and vascular growths, such as Dsevi and heemorrhoids. 7. Trawnatic. — Certain parts of the alimen- tary tract are, from their position, more liable than others to external injury. Incised and punctured wounds of the mouth, oesophagus, stomach, intestines, and liver are of occasional occurrence, and rupture of the abdominal tissue is sometimes met with. The injection of corrosive substances may produce destruction of certain parts of the canal, and wounds may be deter- mined by foreign bodies, as pins, flsh-bonesi &c., whitih have been swallowed. III. Malformations and Malpositions. 1. Eisreditan/. — Of these the most important are hare-lip ; cleft palate; fistulous communica- tion between the pharynx and the exterior, or between the gullet and trachea; intes.tinal caeca; imperforate anus ; herniae. ?. Acquired. — ^Malformation and malposition of the viscera may follow from disease. Com- munications between the stomach and intes- tines, or between different coils of intestine, or between the gall-bladder and the gut, may result from chronic ulceration. Many hernise are not developed until long after birth, from violent strains, &c. Stricture of various parts of the canal is fre- quently associated with the healing of ulcers, and with new growths. Dilatation of the canal is apt to occur in the proximal, and contraction on the distal side of such strictures. The intestines may be considerably displaced from adhesions following peritonitis. Twists (vol- vulus), intussuBception, internal strangulations. DILATATION. 373 and prolapsus ani, are more or less common affections of the intestines. IV. Abnormal OoutentB. — Concretions, chiefly of phosphate of lime, are found occa- sionally in the intestine. They usually are made up of consecutive layers of material de- posited by the mucous membrane. They fre- quently have as a nucleus some foreign body. Similar bodies formed of chalk or magnesia which has been swallowed have been met "with. Foreign bodies, such as pins, bones, fruitr-stones, coins, &o., may also lodge in the alimentary canal. Parasites. — The chief of these are Saroina ventriculi, in the stomach; Taenia solium; T, mediocanellata ; Bothriocephalus latus ; all in- habiting the small intestines. Taenia Echino- coccus (hydatid) in the liver. Ascaris lum- bridoides, chiefly met with in the small intestines; and Oxyuris lumbricoides (thread- worm) almost confined to the rectum. A tew otiier species are rarely found. The gases of the intestines may be so largely increased in quantity as to constitute an ab- normal condition. W. H. Almhin. DILATATIOIT {dilato, I enlarge). MnasjosY. — Dilatation of any of the cavities, tubes, or orifices of the body may either result from increased pressure from within, or from diminution in the resisting power of the walls of the tubes or cavities. These two causes are frequently combined, and, indeed, the latter is often the result of a long continuance of the former. Increased pressure from within may bo due either to increased secretion of the normal contents of the cavity, or to some other effusion into it. This is the usual cause of dilata- tion of the closed cavities of the body; we have examples in the ventricles of the brain, the peri- cardium, the synovial cavities, the bursas, the foUicles of the thyroid body in cystic goitre, and the Graafian vesicles in some forms of ovarian dropsy. In the various tubes of the body, in- creased pressure from within may arise from obstruction, and the consequent accumulation behind the seat of obstruction of the substances which it is the function of the tubes to transmit. Vakieties akd GHARiCTEEs. — 1. Ch/stic dilata- tion. — In tubes which begin by blind extremities the result of dilatation is generally the forma- tion of a cyst, and this is the usual mode of origin of the large class of retention-cysts, or cystic dilatation. We have examples in' the sebaceous cysts, in the cysts of mucous mem? branes due to the ducts of the mucous glands becoming obstructed by the products of catarrhal inflammation, in cysts of the kidney formed by dilatations of the Malpighian capsules and uriniferous tubules, and in dilatations of the gall-bladder, and of the pelvis'of the kidney. 2. Uniform, or cylindrical dilatation.- — In tubes not beginning by blind extremities, the effect of the obstruction is usually to prodiice a iiniform or cylindrical, and not a cystic dilatation; though sometimes one part of the wall will yield, and so cause a diverticulum or sacculus. These uniform and cylindrical dilatations may occur in all the tubes of the body. They are met with in the 374 DILATATION, tesophagus and all parts of the digestire canal, in the heart, reins, Madder, ureters, bile'ducts, &c. This form of dilatation may be attended either ■with thickening and hypertrophy, or -with thin- ning and atrophy of the -walls. Usually, when the tubes are in the main muscular, hypertrophy occurs, from increased exercise of the muscular fibres in their efforts to overcome the obstruction ; but when the walls are mainly fibrous or elastic, they generally become atrophied and thinned. 3. Compensatory or collateral dilatation. — An- other form of dilatation from increased internal pressure may be termed compmsatory or oolla- teral dilatation; it is produced by the tubes haying to transmit an increased quantity of fluid in consequence of the obstruction of other channels. Besides the blood-vessels, we may meet with examples of compensatory dilatation in one ureter when the other is blocked, anH in the bronchial tubes and other parts. Eesembling this form in its mode of origin is the dilatation caused by tubes having to transmit substances of too large a calibre, as, for example, in the pas- sage of calculi down the gall-duct and ureters. i. Dilatation from changes in the watts. — The last class of dilatations consists of those due to diminished power of resistance in the walls of the tubes or cavities. The most important ex- amples of this class occur in the circulatory and respiratory systems; in the heart from fatty degeneration ; in the arteries from atheromatous changes. In the respiratory organs it occurs both in the bronchial tubes and in the air-cells. Here, however, the loss of resisting power is itself usually caused by prolonged increased pressure from within ; which in the air-cells, as their walls are elastic and not muscular, rapidly causes atrophy, and subsequent dilatation. W. Catlbt. DILTTEITTS (diZ«o, I wash or dilute). Definition. — Eemedies which increase the proportion of fluid in the blood. Enumeeation. — Water is the only real diluent. It is given for this purpose in various forms — soups, ptisans, barley water, toast and water, milk, lemonade, aerated waters, &c. — to quench thirst, and increase secretion. Uses. — Diluents are employed to lessen thiTSt, as in fever and diabetes. As the thirst may depend upon local dryness of the throat, as well as upon general want of fluid in the system, the power of water to quench thirst may be greatly increased by adding to it a little vegetable, or mineral acid, or some aromatic, such as lemon or orange peel, which will stimu- late the flow; of saliva, and thuis tend to keep the mouth moist after the liquid itself has been swallowed. The thirst-quenching power of water is also aided by the addition of mucila- ginous substances, such as oatmeal, or linseed as linseed-tea, which, leaving a mucilaginous coat on the inside of the mouth and pharynx, retard evaporation, and thus lessen the dryness of the mucous membrane. ,T. LiUDBE BBTOtTON. DIPHTHERIA (Si^e4pa, a skin).— StNok. : Fr. diphtherie, diphthirite; Ger. Diphtheritis. Definition. — A speoiflc, contagious, asthenic, general disease, which sometimes prevails as DIPHTHERIA. an epidemic, and is endemic in certain places, It is characterised by the exudation in varioui situations — ^paiticulariy on the mucous surface of the soft palate, uvula, tonsils, pharynx, larynx, and trachea — of a peculiar cacoplastic lymph, which, together with epithelial cells, generally forms a thick, tough, and stratified pellicle or false-membrane — a stroma made up of mucous and epithelial cells, arranged in layers of the cacoplastic exudation. Name and Synontms. — In 1826, Bretonneau of Tours, in his work, entitled Becherches, S[c. sur la Diphthirite, created the name, and first pointed out the true pathology of the disease. In his latest memoir (1865) he substituted the t&m diphthirie for diphth&ite, having dis- covered that the disease is not of an inSamma- tory character. Diphtheria was a word almost unknown in English medical literature till 1859, when theSydenham Society published a volumeof memoirs on the disease, translated by Dr. Semple from the French of Bretonneau and others. The name, slightly modified, has now been appro- priated by all European languages; and at pre- sent there is no other word which can correctly be said to be synonymous with it, although it is equally true that the disease diphtheria has been described under many names, without, however, an exact appreciation of its distinctive character, by Hippocrates, Celsus, Sydenham, and others, from the dawn of medical history to the present day. ' Croup,' in cases named and described by Home, Cheyne, West, and others, is identical with Bretonneau's ' croup,' which he 'also calls tracheal and laryngeal diphtheria; but, never- theless, croup and tracheal diphtheria being de- scribed by the majority of British authors as different diseases are not in a, literary sense synonymous terms. Geographical Distbibction Epidemics of diphtheria have occurred in many countries far apart from one another, and differing essentially in physical features and climate. " In recent years the geographical distribution of the dis- ease seems to have become greatly extended, a circumstance which is probably attributable to the increasing intercommunication of peoples. Diphtheria has its favourite localities— localities in which it is always endemic, and frequently epidemic. Among such places may be parti- cularly mentioned Florence and Paris. iEiioLoaY. — The disease is contagious. Apart from endemic and epidemic causes affecting its maintenance in foci, and its outbursts at par- ticular times and in particular places, there are Betiolo^cal influences belonging to individuals in respect to : — 1. Accidental Predisposing Causes ; 2. Age ; and 3. Heredity. 1. Accidental Predisposing Csmm.— Poverty and its concomitants — unventilated filthy lodg- ings, scanty clothing, and imperfect alimentation — impart to individuals a receptivity for the eontagium of diphtheria. A similar receptivity exists in tuberculous persons and in all cachectic subjects. Scarlatina, measles, and whooping- cough peculiarly predispose to diphtheria. In twenty years, Barthez observed 605 cases of scarlatina : in 95 of them, that is, once in about DIPHTHERIA. 376 STery six oases, diphtheria ooeuired as a secondary disease. Diphtheria of the air-passages may occur also as a secondary disease after a common inflammatory sore-throat, a circumstance -which has led some to hold that diphtheria is an in- flammatory disease. Eecently-delivered women receive easily the diphtheritic poison. During epidemics the influence of the predisposing causes now enumerated is sometimes strikingly exemplified. 2. Age. — Diphtheria is most common between the ages of two and ten.- Few persons are attacked after thirty ; but there are occasional victims at all ages, from the earliest infancy to old age. 8. Heredity. — Diphtheria is not an hereditary disease ; but a special aptitude to receive and develop the poison evidently pertains to certain individuals and families. This statement is borne out by the statistical enquiries of Morelli, Nesti, and others in relation to the recent epidemics of Florence ; but the facts which establish it beyond a possibility of doubt are the numerous cases of particular families being desolated by diphtheria at intervals of years, and when the members attacked were widely separated. For example, a child died this year of .diphtheria in Paris : a sister died of the same disease two years ago in Florence : about the same date, an elder brother similarly perished at the Cape of Good Hope : and the mother of these children was in child- hood nearly carried off by the same disease. Family histories of this kind are so numerous, as to lead to the conclusion that there is often a certain stamp of similarity of constitution per- vading a family, in virtue of which its members are specially disposed to receive and develop the diphtheritic contagium. Natubai, CoTJHSE.^-Diphtheriahas a tendency to run a definite course, as may be well seen in caaes which are benignant or of moderate severity. In the cases termed benignant by authors — cases more numerous in some epidemics than in others, and commonly met with at the begin- ning and decline of most epidemics — the disease runs its entire course in from eight to ten days. In this class of cases complete and rapid recovery often takes place, not only without medical treatment, but also in spite of the most objec- tionable measures having been adopteld.' In many benignant cases the exudation is limited to the tonsils and pharynx, but sometimes it in- vades the larynx and trachea: nevertheless, under both circumstances, the false-membrane be^ns to loosen spontaneously, and to be got rid of between the fifth and seventh dSy. In cases of very malignant type — both in those which set in suddenly with intense symptoms, and in those which begin insidiously — the disease may run its course from health to death in less than one day, or, according to the greater or less severity of the poisoning, the fatal issue, or the dawn of recovery, may not occur for several days, Inotibaticm. — There is a great diversity of opinion as to the maximum period of incuba- tion ; but the general opinion is that it does not exceed a few days. There are facts and reasonings, however, which suggest the pos- sibility of the diphtheritic poison remaining dormant in the system for weeks or months, till called into activity by favouring circumstances. Invasion. — The invasion of the disease is gene- rally occult and insidious. Slight fever, drowsi- ness, general discomfort, a little languor, loss of appetite, prostration, diarrhoea, rigors, pallor, tickling cough, husky voice, and hoarseness, often usher in diphtheria ; but as these symptoms, separately or in conjunction, may occur in children from a multiplicity of causes, they assist in form- ing a diagnosis only when careftiUy studied in conjunction with one another, and with surround- ing circumstances. It is, therefore, very difficult in most cases to fix the exact date of the com- mencement of the disease. Three or four days may be passed without the manifestation of characteristic signs, the patient during that time presenting no marked indications of seriously deranged health. The invasipn- symptoms are sometimes so slight as entirely to escape notice. The disease may suddenly explode, without the smallest warning, by an attack of stridulous breathing; on looking into the throat we may then find false-mem- brane covering the tonsils and pharynx, and extending into the air-passages, so as dan- gerously to obstruct the passage of air into the lungs, and excite spasinodic exacerbations of dyspnoea. Sometimes, on the first, second, or third day of the disease, the patient is carried off before any exudation has taken place, the patient dying in a state of profound prostration from primary toxaemia. The dijjhtheritic poison sometimes kills without producing the diphthe- ritic pellicle. Symptoms. — The symptoms of diphtheria are general and locaL Thegmeral symptoms of pharyngeal, laryngeal, and tracheal diphtheria are those of the general specific disease of Which they are local manifes- tations. Wherever the false membrane is situ- ated — whether on the tonsils, pharynx, larynx, trachea, bronchial tubes, nares, eyelids, vulva, vagina, uterus, anus, or on a wound, ulcer, or cutaneous abrasion — its nature is the same. The general symptom never absent is prostra- tion ofetreiigth-. the local symptom absent only in a very few exceptional cases is the formation of false^membrane. The other symptoms of most importance, but which are more or less fre- quently absent, are albuminuria, change of tem- perature, cutaneous eruptions, enlarged glands, and paralytic affections, 1. Prostration of Strength.^iyna is a constant symptom, but its degree is very variable; Some patients succumb to the primary shock of the poison. In rapidly fatal cases, however, there are degrees of rabidity — there is a gradation of cases from those in which death takes place in less than a day without any characteristic sign except prostration, to others in which time is afforded for the formation of false membrane, and the development of some or all of the symp- toms mentioned above. 2. Formation of False-Membrane. — There is always an exudation of false-membrane unless the patient be cut off before there has been time for its formation. The nature of the false- membrane has been already briefly described in the definition of diphtheria. Its existence i« 378 sometimes not discovered during life ; as, for example, in those rare cases in frhich the exuda- tion commences on the lining of the bronchial tubes, and occasions death by asphyxia before it has extended upwards to visible parts. As a gene- ral rule — with, however, about two per cent, of exceptions — the exudation bpgins on the tonsils or pharynx, and next, but not always in con- tiruity, on the larynx. From one to five, six, or even seven days may elapse between the first appearance of false-membrane and its exudation on the mucous membrane of the larynx. 3. Albtuninuria. — ^Albuminuria is very com- monly met with. The third and fourth days of the disease are the most usual for the first appear- ance of this symptom ; but it may occur on any day from the second to the twelfth without the occurrence being considered unusual. It is some- times permanent for days, and sometimes con- tinues for weeks afterconvalescence has begun. Its duration is from one to sixty days. It is often intermittent, and still more frequently — without quite ceasing — its intensity varies at dififerent periods of the twenty-four hours. It does not necessarily indicate a morbid state of the kidney, and — unlike the albuminuria of scarlatina— ^it is not associated with dropsy. It originates in different causes, which sometimes operate sepa- rately or in combination. Probably the chief causes are the rapid waste of tissue and the altered state of the blood, which are very early eiFects of the poison of diphtheria ; there conse-. quently arises a sudden necessity for an enor- mous discharge of effete matter by the kidneys. Another cause, one likewise almost always in existence, is tlie ingestion of aliment much in excess of assimilative power; the intermittent character of this cause is probably the explana- tion of the frequently intermittent character of the albuminuria. A pulmonary cause of albu- minuria frequently comes into operation, as in pneumonia, and during the death-agony from all diseases. Obstruction of the air-passages by false-membrane induces albuminuria by produc- ing great congestion of the lungs with more or less asphyxia. Finally, a renal cause may occa- sionally exist in pre-existing disease of the kidneys ; or, secondarily, in their simple conges- tion from the strain of the extra-work, and their functional feebleness through general deficiency of innervation. The proportion of cases in which albuminuria occurs for one or more days is about one in three cases ; but the proportion is different in different epidemics. Albuminuria is not a sign of danger ; its prognostic signi- ficance belongs not to itself, but to its cause or causes. 4. Changes of Temperatitre. — High tempera- tures prognosticate danger; but moderate or even normal temperatures are often met with in rapidly &tal cases. 6. Cutaneous EkwpHoni. — Eruptions, varying much in appearance, are sometimes seen in the course of diphtheria. They seldom continue more than three days, and are sometintes visible for only a few hours. If the eruptions themselves were the only guides to diagnosis, the malady might be often mistaken for scarlatina. The eruptions of diphtheria which simulate those of scarlatina are sometimes vesicular, sometimes DIPHTHEHIA. like urticaria, and sometimes they occur in bright red patches — rubeolar, roseolar, or erythematous. They are not followed by desquamation, as in scarlatina. The appearance or non-appearance of these eruptions does not influence the prognosis. Kccbymoses due to blood-poisoning may also occur,' and are of course of very serious import. 6. Enlarged Glands. — Glandular engorgement is often one of the earliest indications of diph- theritic poisoning. It is not a secondary result of the throat-manifestation, but belongs to the general disease itself. In the recent epidemics of Florence, described by Morelli and Nesti, turgescence of the cervical glands is mentioned as a symptom commonly associated with general anasarca, and an eruption of red, pink, and dark red points on the face, neck, chest, and abdomen. This eruption was sometimes visible for only a few hours, and never for more than three days. 7. , Paralytic Affections. — This important sub- ject is only named in this its natural place, its consideration being more conveniently reserved for a separate article. See Paealtsjs, Diph- THEBITIC. DiAONOsis. — When diphtheria has proved fatal too soon to afford sufficient time for the mani- festation of its characteristic symptoms; and also, when the invasion-stage is insidious, the diagnostic difficulties are great. Sann£ believes that the affection designated ' throat-l^erpes ' ijKfrpes guttural) by Gubler is a form of diph- theria, an opinion 'which, if erroneous, is not easily controverted. The difficulty of the dif- ferential diagnosis fuUy explains an opinion, repeated by several authors, to the effect that the diphtheritic nature of an affection cannot be declared with certainty till the membranous deposit has been seen to extend from the tonsils and pharynx to the respiratory passages. Some physicians, among whom is Trousseau, think that the herpetic nature of the affection is estab: lished when an eruption of herpes appears on the lips. Sanni says : 'Diphtheria commences with local phenomena which are very varied : the form and disposition of the false-membrane are insufficient to enable us to predict the nature of the malady, or to form a prognosis regarding it.' He adds, and with truth, if the statement be accepted only as a provisional clinical fact: ' This is one of the most important aphorisms in the doctrine of diphtheria.' Pathologically, liowever, there can be no diagnostic difiSouItjr in these cases , if it be true, as an increasing number of physicians believe, that membranous sore- throat is always diphtheritic. PuoQNOsia. — The younger the subject, the less are the chances of recovery. This arises, from two causes, viz., the smaller power in infancy to resist depressing influences ; and the narrowness of the larynx in infancy and childhood. The elements of prognosis belong in part to the in- dividual case ; and are in part common to all the cases occurring at the same time and place, First, in respect to the individual element The prognosis .is unfavourable if false-membrane has been deposited, and continues to be formed on the mucous membrane of the air-passages during the first three or four days of the disease ; on the other hand, the prognosis is favourable if these days be passed without formation of false- DIPHTHEEU. 377 taemtrane on the air-passages j but only pro- visionally faTourable, for a sudden membranous invasion of the air-passages may occur during that period. If at the seventh day the air-pas- sages be not invaded, if there be adequate cardiac power, and if a fair amount of aliment be regu- larly assimilated, the prognosis is very favourable. We must, however, take into account peculiari- ties of constitution, the presence or absence of disease prior to the attack of diphtheria, and also the exact significance of each symptom in respect to its individual gravity, its grouping with other symptoms, and the period of the malady at which the prognosis is made. Secondly, in respect to surrounding circum- stances. In cold damp weather the mortality is greatest. The medical constitution of the season, and the character of an epidemic greatly influence prognosis. In some epidemics, in which the local manifestation of the disease is limited to the pharynx, recovery takes place in nearly every case. In an epidemic which prevailed in France in 1847, the mortality was 91 per cent. In the first quarter of 1876 the mortality from diphtheria in the hospitals of Paris was 79'79 per cent., whereas in the six preceding years it averaged only 76'54 per cent. Anatomioai, Chakactebs. — The lesions found after death from diphtheria are priTnary and secondary. The primary are those found in persons dying during the natural course of the disease ; the secondary are not direct results of diphtheria, but are consequent upon the compli- cations and retardations of abortive convales- cence, 1 . Primary lesions. — In persons who die during the first two or three days of the disease, in whom there are no complications, and in whom there has not been time for the formation of false- membrane, the only morbid appearance found on dissection is sanguineous congestion of themucous membranes, lymphatic glands, and internal or- gans. In those who live a few days longer, say till the seventh or eighth day of the disease, a similar state of congestion is met with ; and there are found on mucous surfaces, particularly on those of the pharynx, larynx, and trachea, layers of the characteristic pellicle. The only primary morbid appearances of diphtheria, visible to the unaided eye, are congestion of organs, and false-membrane on certain mucous surfaces. To these has of course to be added a dysorasia of the blood, which probably exists from the very beginning of the attack. • 2. Secondary lesions, which are numerous, vary according to the nature and duration of each case. It is. particularly noteworthy that in the secondary, ansemia replaces the hypersemia of the primary morbid conditions. To the general statements nowmade in reference to the morbid anatomy of diphtheria, there are numerous exceptions; and as one of the more important of them may be specified pseudo- membranous deposits in the bronchial tubes, and hepatisation of the lungs occurring as early as the second or third day. A^ brief sketch of some of the secondary lesions of diphtheria is subjoined : — I^fmphaUe glands. — The submaxillary and .parotid are the most asually and the most acutely affected : next in order of frequency come the superficial cervical glands, the deep cervical glands, and the mesen- teric glands. Glands sometimes suppurate : when this takes place the pus is generally found in small circumscribed dep6ts. They are sometimes infiltrated with a brownish sero-sanguinolent fluid: sections of glands so affected resemble sections of the healthy spleen. The inner ear. — This is sometimes invaded by false-membrane, extending from the skin of the outer ear, or advancing by the Eustachian tube from the pharynx. Comiective tissue. — Sanguinolent and . sanguineous efiusions are sometimes found in the connective tissue, particularly in that sub- jacent, to mucous membrane coated with the diphtheritic pellicle. In it abscesses are also met with, in the contiguity of engorged and suppurating glands. Muscular tissue. — In pro- tracted cases of paralysis, the muscles of the arms, legs, chest, and eye-ball are often found to be more or less in a state of fatty or waxy degeneration. The muscular tissue of the heart is likewise sometimes similarly affected. Lungs. — Besides the primary specific lesions wo may find on dissection anatomical evidence of simple bronchitis, pneumonia,, and pulmonary 'apoplexy having occurred as secondary affections. Trachea. — Cases have been recorded in which the trachea has .been found ruptured, the result of a desperate struggle for breath. In tracheotomy- cases, the pressure of a badly adjusted canula has frequently caused ulceration of the trachea. The cicatrisation of the ulcer sometimes pro- duces stricture of the passage. Mediastinum. — Abscesses of the mediastinum oecasionally follow tracheotomy. Kidneys. — A form of superficial parenchymatous nephritis, resembling the char- acteristic lesion of scarlatinal albuminuria, is said to be a common pathological condition in diph- theria. Perhaps \mi.ei the toTca parenchymatous nephritis many cases of simple hyperaBmia are included. The condition of the kidneys in diph- theria requires, however, further investigation. The granular and other, degenerations of the kid- ney described as having been met with, have pro- bably no peculiar or direct relation to the diph- theria. They may either represent disease which existed prior to the diphtheritic attack, or disease resulting from the general damage to the system induced by that attack, just as it might have been produced by an att^k of some other debilitating, blood-disintegrating malady. Be that as it may, it is important to note that in patients who die in the first days of an attack of diphtheria after having had intense albumi- nuria, the only discoverable morbid condition, of the kidney is moderate or considerable, con- gestion. Sann^ explains the rarity of the oc- currence of oedema and cerebral symptoms in connection with diphtheritic albuminuria by the fact that one kidney only is affected and not both, as in scarlatinous nephritis. Nervous a/stem. Even when death has been preceded by pro- tracted paralytic affections, the most minute microscopic examination has generally failed to detect any morbid change in the encephalon or spinal cord. On the other hand, in pro- tracted cases of diphtheritic paralysis, various alterations in the nervous periphery are fre- quently found. 378 DIPHTHERIA. Pathology. — Diphtheria is a poison-disease acting primarily upon the whole system; the exudation of oaeoplastio lymph is a manifest- ation of the general poisoning, and not, as Trousseau taught, an infection of the patient by the absorption of the poisonous material of the false-membrane. Gangrenous decomposi- tion of the false-membrane sometimes, how- eyer, becomes a source of secondary toxemia. The poisoning is then not diphtheritic; it is simply the result of the absorption of putrid matter, Tebatmbnt. — Few diseases more severely tax the ingenuity and therapeutic resources of the physician than diphtheria. He has to devise and carry out innumerable little details — hygienic, dietetic, and medicinal — which do not admit of minute description, and yet upon the minutiae of which success or failure frequently depends. The treatment must be carried out on a rational basis, no special trust being placed in nostrums, or in any of the so-called specifics announced in earlier and later times, and some of which are still recommended by honest enthusiasts of limited experience. It is requisite to pay the utmost attention to the hygienic surroundings of the patient. From the first it is necessary that decided and well-considered measures be carried out to support life, by the administration of alcoholic stimulants and of easily assimilated aliments. JKedicines whichfiave a depressing in- fluence on the nervous system, or which tend to produce dyscrasia of the blood, are to be rigidly avoided. Prostration of strength and dissolution of the blood are conditions which exist to a greater or less degree in every case of diphtheria ; and for that reason, the abstraction of blood, purging, and the use of alkalies, mercurials, and antimonials are inadmissible. From first to last sustaining and recuperative treatment — alimentary and medicinal — is the great aim. If life be maintained for a certain number of days, nature, even in very severe cases, makes a decided curative e£fort : in other words, when the disease has run its natural course, there is a greater or less attempt at spon- taneous recovery. The moment has then arrived when the physician can most usefully intervene with his culinary and pharmaceutical resources. It is his therapeutic opportunity. A somewhat varied and well-planned pepsinated aliment and ferruginous medication, which had up to that stage produced little benefit, will then wonder- folly assist nature in accomplishing a cure. The principal details of treatment may be considered under the following heads : — 1. Hy- giene. 2. Diet. 3. Stimulants. 4. Medicines administered internally. 6. Applications to the throat and air-passages. 6. Tracheotomy. 1. Hygiene. — The covering of the patientmust be light ; and yet such as to prevent loss of animal heat. The placing of one or more caout- chouc bags filled with hot water under the bed- clothes, close to the patient, is a simple and an admirable method of keeping the body warm, and of enabling the windows to be opened from time to time, without risk, to relieve the dis- tressing air-hunger, when there is obstruction of the air-passages, intensified by the close atmosphere of a badly-ventilated room. The temperature of the room ought to vary little^ a temperature of about 60° F. being maintained. The patient ought Vi bo carefully screehed from currents of air, care being taken that free venti- lation is not interfered with. - A thermometer and a steaming kettle are indispensable in the room of the diphtheritic patient. After tracheo- tomy, the maintenance of good ventilation, com- bined with an equal temperature and a warm moist atmosphere, is a paramount necessity ; ami, in all cases, and in every stage of cases in which there exists diphtheritic sore-throat, it is impor- tant, as a means of moderating the paroxysms of glotto-pharyngeal spasm, that the air inhaled be soft and warm, and that the temperature be equable. Even in the rare cases in which throat- affection is absent, it is the duty of the physician to take the measures best calculated to secure such an atmosphere as has now been described, for the disease may at any moment manifest itself in the air-passages. 2. Diet. — Nutriment is urgently demanded; butit is useless — nay, it is mischievous — to push attempts at alimentation beyond very moderate limits, so long as the malady is in the ascendant. Assimilation is then very nearly at a standstill, as is shown by the rapid emaciatiba which goes on, even when large quantities of food are being put within the patient, and likewise also by the albumin which is passed with his urine. The albuminous urine of diphtheria arises from dif- ferent causes ; but, speaking in general terms, it is correct to say that it arises from no renal lesions, and is the expression of rapid waste of tissues and of the non-assimilation of food. Alimentation is the most important, and also the most difficult part of the treatment. Patients — even intelligent adults — often resolutely refuse food, and feel intense loathing, excited by the mere sight or mention of any alimentary sub- stance, and the food taken is generally rejected at once by vomiting ; or if retained it is very sparingly assimilated. To press food upon chil- dren in spite of their loathing of it is generally injudicious : to press it upon them in spite of their struggles is sometimes even dangerous, as the excitement and resistance takes more strength out of the already prostrate patient than can be compensated for byforcibly administered aliment. We ought to try quietly to get the child to take frequently small quantities of milk or beef-tea ; and when we fail, we must give enemata of beef- tea and brandy. The food given to diphtheritic patients ought to contain pepsine. The quantity administered must of course be proportionate to thatof the food. In respect to the dose of pepsine, it is necessary to remember that genuine British pepdna foroi is four or five times as potent a digestive as Boudault's pepsine, the mixture generally pre- scribed in France. Pepsinated pills of pounded raw beef, with a few teaspoonfuls of the ex- pressed juice of raw or slightly roasted beef, are exceedingly useful in keeping patients alive while the disease is expending its immediately de- structive powers. When the irritability of the stomach does not forbid the trial, strong egg- flips may be given. A strong egg-fiip may be made by beating up together one teaspoonful of concentrated Swiss milk, one teaspoonful ox DIPHTHERIA. 379 btnndy, and two or three teaspoonfuls of water. To these ingredients, two grains of pepsina porai may be added. Patients -who hare moderately aeTere attacks of the disease, and convalescents, can generally take such semi-liquid aliments as panada and chicken purh [purie d ki reine]. Occasionally, but not generally, patients can take cod-liver oil. Milk ought to enter largely into the diet of diphtheritic convalescents. In them, as in all convalescents, it is an admirable mainstay ; but there are some few cases in which it does not agree. 3. Stimulants. — ^Diphtheritic patients emaciate rapidly ; and together with, as well as before the loss of flesh, extreme prostration occurs. Under such circumstances, the liberal exhibition of alcoholic stimulants is imperatively demanded as the principal, and when food is rejected, as the only means of supporting life during the most critical period of the disease. This great crisis is not generally prolonged for more than a few days, but stimuk,nta may require to be more or less relied on for a long time. Sometimes for hours or days it may be impossible to give any- thing more than stimulant^ of which the best are alcohol in some form, tea, coffee, and the juice of meat. When all kinds of food and stimulants excite nausea and Vomiting, it is necessary to discontinue for a time nourishing the patient by the mouth. For some hours — ^for from six to twelve hours — he must be fed entirely by the rectum, so that the stomach may have an interval of complete rest. In such cases it is a good practice to precede renewed attempts at feeding by the mouth, by one or two doses of creasote and oxalate of cerium. Both can be given in very small bulk, which is a great advantage ; and no other ga^tro-sedatives act less as depressants of the general system. The ordinary so-called crea^ sote of commerce is bad carbolic acid, which, in place of allaying, frequently excites nausea and vomiting. If pure creasote cannot be obtained, pure carbolic acid may be substituted for it. The creasote may be given made into pill with breadcrumb ; and the oxalate of cerium either in the form of pill, or wrapped in moistened wafer-paper as a pulpy bolus. The proper quantity of creasote to give at one time is from half a drop to two drops, and of oxalate of cerium from two to four grains. In the twenty-four hours we may administer as a maximum, ac- cording to the age of the patient and the cir- cumstances of the case, from six to eight drops of the former, and from twelve to sixteen grains of the latter. Of the crystals, liquefied by heat, one drop is given in a tablespoonfnl of thin wudilage. This may be repeated several times in the twenty-four hours. When the remedies now mentioned have failed, the nitrate of bis- muth in two or three successive doses of ten grains each may succeed. There are cases in which the nausea is so urgent a symptom that it is impossible, by any medicines, to over- come it. We must then trust entirely to the ap- plication of warm poultices, sinapisms, or tur- pentine-stupes to the pit of the stomach. The hypodermic injection of morphia, or the adminis- tratiou' of an enema containing hydrochlorate of morphia, is another method of allaying nausea and vomiting, in the gastric irritability of fever and other diseases, but which is only applicable in a limited number of oases of diphtheria, in those cases in which the asphyxia is' far advanced and is advancing. The quantity of hydrochlorate to be administered in clyster depends much on the age of the patient. Sixty drops of the Liquor hydrochloratia morphise of the British Pharma- copceia may be given by the rectum to an adult, while from five to ten drops is a sufficient dose in clyster for a diild under ten yeats of age. Besides allaying nausea and vomiting, such a clyster soothes, diminishes the severity of spas- modic dyspnoeal paroxysms, and gives the sufferer rest. 4. Medicines administered intemalh/ are usu- ally employed either to accomplish some parti- cular object ; or to exercise a curative influence on the general disease. There is another special object for which in- ternal medicines are given, namely, the detach- ment and expulsion of false membranes from the air-passages. For this purpose the administration of emetics has been considered by many as one of the essential parts of the treatment of laryn- geal, tracheal, and bronchial diphtheria. Their use is unquestionably indicated in certain cases, yet the range of their utility is very limited. There are two circumstances which obviously limit the advantages obtainable by emetics ; first, if administered at an advanced stage of the dis- ease, or at any stage when there exists great prostration, the vomitive efforts excited must act most prejudicially when they do not produce the desired result of expelling the false-membrane from the air-passages^they must difaw danger- ously upon the waning strength of the patient, and diminish his chances of pulling through "with the aid of tracheotomy. Herein lies a greit limi- tation of the use of emetics, because the cases are exceptional in which the blockade of the air- passages is effectually relieved by vomitive ac- tion; and when no such relief is obtained, the violent efforts excited by emetics only produce unmitigated evil — a large withdrawal of remain- ing vital power. Again, unless the exudative stage of the disease be ended, theejeetion of false- membrane affords only a brief temporary respite, for new layers are speedily deposited to replace those which have been thrown off. These con- siderations show the narrow limits within which benefit can be obtained from vomitive action, and how much evil may accrue to the patient when that action is violent. Should it be judged ex- pedient to induce vomiting, the emetic selected ought to be one which generally acts quickly and certainly, and which if it fail to act will not pro- duce dangerous irritation of the intestines or great depression of the system. Tartar-emetie must not be employed. Sulphate of copper, an emetic much recommended by Trousseau and others Tinder the circumstances now being con- sidered, is also objectionable; because if it 'does not promptly cause vomiting, it will be nearly certain to excite enteritis and formidable diar- rhoea. Ipecacuan and sulphate of zinc are perhaps the; safest emetics to administer to a diphtheritic patient. The repetition of dose after dose of any emetic is dangerous practice in diphtheria. For example, we may give, without apparent effect, 38U DIPHTHERIA. Buccessive doses to a semi-asphyxiated patient whose functional life is dormant; and seeing that we give him no relief in the way hoped for, we proceed as our last chance of saving him to admit air into the lungs by tracheotomy. Forth- with the vital powers awake, and tlie accumulated doses speedily act with violence — the patient has been saved by tracheotomy only that he may die of pharmaceutical poisoning. Dr. SannA (Traiti de la Diphtherie, Paris, 1 877) suggests that the recently discovered medi- cine apomorphia might be tried as an emetic in diphtheria. It possesses properties which seem to recommend it very specially in this disease; This drug is administered hypodermioally. It acts very rapidly — in from three to five minutes : and supersedes or greatly reduces the duration of the period of nausea. It frequently succeeds when other emetics have failed to act. The advantiiges which it possesses are, therefore, facility of ad- ministration, rapidity of action, and less fatigue to the patient. The only objection to its general use is the difficulty of preserving it.' Another suggestion of Dr. SannA is noteworthy. He proposes that trial be made of jaborandi, given internally, as a means of producing de- tachment of the false membrane. The medicines which have a curative influence on the general disease are few in. number. Cer- tain medicines — preparations of iron, for example, are, under certain circumstances, particularly, ■ useful in diphtheria. Of the medicines which have had in their day repute as specifics, or as agents of high thera- peutic value, but have now nearly ceased to be so esteemed, a few may be briefiy mentioned. Bromine and ita compounds, sulphuret of potash, copaiba and cubebs, chlorate of potash, sulphite of soda, chloride of sodium, carbolic acid, sali- cylic acid, chlorodyne, calomel, quinine, per- chloride of iron, and many other medicines, have all been proclaimed as specifics, or at least as wonderfully potent in the cure of diphtheria. Perchloride of iron has a decidedly beneficial action under certain circumstances; but this action it possesses in common with other pre- parations of iron. It neither arrests nor modifies the character of the malady in its early and most perilous stages ; but its utility is unquestionable as an adjuvant, when, in the natural course of the disease, a spontaneous curative tendency has begun to manifest itself. 6. Applications to the Tlaroat and Air-passages. — With a view to detach, dissolve, or destroy false- membrane, a greatdiversityof topicalapplications have been employed. Trousseau, and those who wrote under his inspiration, strongly recommended destruction of the false-membrane by various caustics and solvents. In the (1868) edition of his Clinical Lectures which was in the press at the time of his decease, Trousseau insists that the topical treatment is pre-eminently the best treatment of diphtheria, adding that it is as much indicated in this disease as in malignant pustule. Fortunately this doctrine is no longer in vogue, and when topical treatment is still em- ployed in France, it is now seldom by caustics or any irritating substances. Sann^ writing in 1877, expresses the general sentiment of French physicians when he says : — ' Cauterization is now generally abandoned : it has serious drawbacks : it is dangerous : it is useless.' ' The practice of attempting to destroy the false membrane by caustics and powerful solvents is unquestionably mischievous. It irritates the parte and increases the exudative tendency. Jhe free application of the officinal glycerine of borax, by means cf a camel's-hair brush, is at least harmless, andseent to loosen the membranous patches. Frequentlj, washing out the mouth with this preparation, diluted with from four to eight parts of water, is agreeable to most patients, and is useful from the local soothing which it produces. A very dilu- ted solutitin of hydrochloric acid is equally innocuous, and as a mouth-wash is pleasant and cleansing. Lime-water and lactic acid, used separately or mixed, exercise a powerful solvent action on the false-membrane ; and were it pos- sible to apply them to it without their coming in contact with, and thereby irritating the con- tiguous mucous surface, they might be used with advantage, or at least with impunity. A small quantity of lactic acid added to an aqueous solu- tion of pure glycerine or to the glycerole of borax — one part to fifty of glycerine ^-is a favourito topical application with some practi- tioners, and is one which may be used without fear of doing any harm. Catheterism of the larynx, and injection of solvents into the trachea, are now generally looked upon as objectionable measures. They still have, however, their advo- cates. Dr. Young of Florence states, as the result of large experience, that he has seen much benefit result from throwing into the throat every hour, by means of a ball spray-apparatus, a solution of three drachms of lactic acid in eight ounces of lime-water. Notwithstanding much that has been written in a contrary sense, a careful review of the subject leads to the conclusion that very little advantage is derived from internal local applica- tions, that they are often exceedingly mischievous, and ought never to be used withaut.the greatest circumspection. They do not curtail or greatly modify the natural course of the general disease ; and the local benefits which they can confer are limited to soothing the parts, and slightly dirni- nishing the obstruction of the air-passages. Moist warmth applied externally to the throat gives much comfort and is in no way iiijurioiia.' Only soothing, or at least non-irritating sub- stances are admissible as internal applications. It must be remembered that topical 'applica- tions can hardly ever bo employed in young children without exciting resistant struggles,' which agitate and exhaust the patient. The risk of incurring this danger .often forbids their employment. 6. Tracheotomy. — Besides the perils of the general disease — prostrating toxa;mia,diffioult nu- trition, and paralysis of the heart and respiratory muscles — the patient has the special risk of dying asphyxiated from obstruction of the air-massages by false-membrane. This terrible danger is one of very common occurrence. When nature and art have failed to remove or effectually lessen the mechanical impediment to the admission of air to the lungs, the physician has to decide whether there be any reason against hisgiving the patient • Bannfi i TraiU it la DifhMrie, Paris, 1877 ; p. 41* DIPHTHERIA. a chance of life by making an entrance for the air below the membranous obstruction. If this one remaining chance remain in any degree, how- ever small, he is bound to offer it to his patient. Sometimes no such chance remains. 'What con- ditions exclude the possibility of saving life by tracheotomy ? That is the question. It is not whether the case be a favourable one for opera- tion; for every diphtheritic patient is an ex- ceedingly bad subject for any surgical operation. The simple question i? : — Qoes tracheotomy give the smallest chance of life to a patient who without tracheotomy must inevitably die from asphyxia ? The answer to this question may, as a rule, be given in the affirmative, if the obstnio- tion be not below the situation in which tracheo- tomy is performed. If this rule be followed, the operation wiU often be performed in very despe- rate circumstances — circumstances in 'which the probabilities of success are very small compared with those of non-success. When the pseudo- membranous afiection extends to the bronchici tubes — when pneumonia exists — when the diph- theria is an immediate sequel of measles, scarla- tina, or typhoid fever — when the asthenia is ex- treme — or when the patient is phthisical — the probability of the operation saving him is small ; and yet, in most unfavourable examples of the classes now mentioned, success has been obtained. John Bose Cobmack. DIPHTHBBITIO.^Eelating to diphtheria. The term is applied to the membrane farmed in diphtheria ; and it is also associated with certain symptoms occurring in the course of the disease, such as diphtheritic paralysis. See Cboupous. BIPIiOE, Diseases of. See Skuxl, Diseases of. DIPLOPIA (SiirXior, double, and Kirro^uoi, I SBe). — Double vision. See Vision, Disorders of. DIPSOMAWIA (Sf+o, thirst; and fimta, madness). — Sinon. : Oinomania ; Fr. Manie ibrieuse, or eraptUeuee • Ger. TrwakstuM. Definition. — An irritability of the nervous system, characterised by a craving, generally periodic, for alcoholic and other stimulants. .ffinoLOGT. — This peculiar condition maybe brought on by a course of intemperate drinking ; but it is seldom the result of liiat cause alone, and it is not infrequent in persons who have never been intemperate previous to the develop- ment of the morbid craving. The occurrence of this form of insanity, as of other degenerative nervous diseases, may generally be traced in the family history of the patients. But sunstroke, a blow on the head, or other direct injury to the brain may excite it; and it maybe Symptoinatie of epilepsy, orofstructuraldiseaseofthe brain. It may be developed at any period of adult life ; but most frequently declares itself during the pubescent and climacteric periods. Sthpioms. — ^An instability of character and indications of peculiar nervous irritability may generally be recognised as having preceded the distinct development of the craving. It is also nsnal to find such persons as are predisposed to the disorder abnormally sensitive to the influence DISCEETE. 381 of stimulants. Sometimes very small qjuautities of alcohol produce appreciableintoxication. The duration of the periods of craving is variable ; but most commonly they last one or two weeka. The remissions continue for periods varying from two to twelve months. During the period of craving the whole moral being is enthralled by the morbid desire ; and the regard for truth, decency, or duty is generally altogether lost. Moderate indulgence in a stimulant may bring on the morbid craving ; but the desire is fire- quentJy developed without any such introduction. Members of the household in which a patient lives can indeed often recognise the indications of a coming attack by a restlessness and depres* sion which precedes any such indulgence. During the intervals the patient seems, except when the brain has been weakened by frequent attacks, to recover completely; and he gene- rally displays great confidence in his ability to resist the tendency in future. Eepeated attacks always produce a permanent degradation, both intellectual and moral ; and if the patient live long enough he lapses into a state of dementia. It sometimes happens that some cerebral lesion, of -which the dipsomania had been symptomatic, manifests itself in paralytic or convulsive symp- toms; and the appearance of such phenomena is often accompanied by a modification of the craving. Diagnosis. — True dipsomania may easily be, and often is, confounded with more habitual drunkenness. In dipsomania, however, there is, as a fundamental condition, a pathological con- dition of the brain which manifests itself irre- spective of external circumstances of temptation. In habitual drunkenness the craving consists mainly in a desire to keep up a condition of stimulation to which the brain has become accustomed. The habit is the result merely of compliance with a vicious custom, and there is no such periodicity or independence of external influences, in the symptoms as is found in the true disease. TfiBATMENT. — - Prolonged abstinence from stimulants, and adherence to the tonic regimen, are the only measures from ■which any ameliora- tion can be hoped for. It is seldom possible to restrain the gratification of the craving without seclusion in an asylum or some similar institu- tion; and. even when such compulsory restraint has been successfully enforced for a considerable period, the morbid tendency is seldom eradicated. The present state of British law does not, how- ever, permit us to confine either the dipsomaniac or habitual drunkard imless something more moi^ bid than an abuse of stimulants can be alleged. And. it is difficult to see how a lavf could be enacted ■which would be effectual ■without being open to serious abuse. Public attention has, however, been lately very earnestly directed to the subject, and it may be hoped that something ■will be done towards rendering efficient treat- ment possible. John Sibbald. piSOKBTE (discerno, I separate). — This adjective is used in reference to certain cut.aneous eruptions in ■which the spots or pustules are separate from each other; for example, discrete small-poz. 382 DISCUTIENTS. DISOUTIEM'TS (^dUcutio, I drire a-roy). Definition. — Local applications, -which are supposed to remove the congestion and effusion of inflamed parts, and the swelling of the skin over them. ' Endmbration. — The chief discutient measures or agents are: — ^Friction; Pressure; Mercury and its preparations ; Iodine and its prepara- tions, including the Iodides of Potassium, Lead, and Cadmium. Uses. — These remedies are generally applied over enlarged joints, enlarged glands, or cystic tumours. The most powerful amongst them are mercury and iodine and their preparations, either alone or in comhination. Their action is aided by heat and pressure. The eflFect of the former is seen in the Indian treatment of goitre, which consists in ruhbing iodide of mercury ointment over the tumour, aai exposing the patient to the full rays of the sun, or to the warmth of a large fire. The beneficial effects of pressure are ob- served in the diminution which takes place in enlarged and swollen joints under the application of mercurial ointment or strapping, the frictfon with the hand in applying the ointment, and the pressure exerted by the strapping greatly in- creasing the eflcaey of the mercurial preparation in removing swelling. See Fkiction. T. Latjdeb Bkunton. DISSA3S {dis, from, and aise, ease). — Fr. Maladie; Ger. Kranhheit. DEHHinoN. — Disease may be defined as a deviation from the standard of health in any of the functions or component materials of the body. See Patholoqt. The expression ' a disease ' is frequently used with reference to a supposed unit of causation. Thus, it may be applied to some simple phe- nomenon, for example, neuralgia, when that phe- nomenon is the sole effect of a cause ; or it may include many concurrent or consecutive resultant phenomena, such as those of syphilis or typhoid fever. GrENEEAL CoNSTDEHATioNS It is woU known that changes of function and of structure are brought about and influenced by a great variety of agencies. These agencies, some of which act from within, others from without, are recognised as the causes of disease. Such changes, whether they be functional, affecting more especially the vital properties of the body, or structural, affecting its physical properties, constitute what is familiarly known as Disease, which is hence called respectively /wBcfe'oMai or structural. These changes are merely the evidence of an altered or perverted action, which is then in operation or has already Occurred, the nature of which is considered under the head of pathology. When these deviations from health can be recognised during life they are described as the symiptomi or signs of disease. For example, when a person, after exposure, it may be to wet or to cold, or both, is found to have an increased temperature, with a quick pulse and perverted secretions, and to complain of thirst, and pain at the joints with effusioii in and around them, we say that such person is laboxiring under disease, and we call it ' rheumatism,' because that name has been as- signed to a oomplexus cf deviations from health, DISEASE, CAUSES OF. such as those then presented by this individual. When typhoid poison has been introduced into the body, it leads in like manner to a number of functional and structural changes, which, taken together, constitute what we call 'typhoid fever,' Or again, under ceKain circumstances there ap- pears to be generated in the ^stem, whether as the result of a tendency acquired befoM birth or by-habitsof life, anagency which, acting morbi- fieally, produces a series of phenomena which we call ' gout.' These several forms of disease may be classified in groups, arranged in accordance wJth the causes which give rise to them, their nature, their seat, their duration, &c. Eules are laid down for the modes of distinguishing or diagnosticating one disease from another; for prognosticating, as far as may be, their result ; and for their prevention and treatment. Thus it comes that the discussion or description of any particular disease consists of an account of the causes that give rise to it, or its .ffiiioLoat; the changes of structure or of iiinction which constitute it, that is, its Anatomical Chabactebs and Patholoqt ; the phenomena attending these changes, otherwise, the Symptoms and Sighs of the disease ; the facts that serve to distinguish this particular disease from other diseases, that is, its DiAQNOSis ; the means of forecasting its progress and termination, which constitute its Pkognosis; and finally the measures by which it may be prevented, relieved or removed, that is, its Treatment. Throughout this work the various diseases are, as far as may be practicable, discussed upon this uniform plan. As thus understood — and it is well to re- member it — Disease is an abstraction or relation, and not an entity having a special and inde- pendent existence. Physiology has in recent days diffused a clear and penetrating light over many of the processes of life in health, which were previously dark and obscure. Pathology, which is physiology applied to the study of un- healthy function and structure, anxiously follows the footsteps of the sister science. We are there- fore not hoping and believing too much when we express our conviction, that the time is not re- mote when we shall be able to trace those early and minute changes which constitute disease, and the causes which give them origin, and that we shall thus be enabled to define in a more philo- sophic and practical form what disease really is. In the meantime we must be content to work upon the phenomena before us, to investigate so far as we can the causes of disease, how to recognise its presence and its nature,, how to estimate its progress and its duration, and finjally how to prevent its occurrence or to cure it when it has occurred. These varied and important points will be found discussed as above stated under suitable headings, in the articles imme- diately following, and in other parts of this wort E. QuAiN, M.D. DISEASE, Causes of. — Definitiok.— Whatever is capable of damaging thei structure of any organ or tissue of the body, or interfering with its iunction, may be a cause of disease. This definition implies that such i causes are numerous, and that of many science is yet ignorant. To give a succinct account of them DISEASE, CAUSES OF. S83 is therefore difficult, nor is this difficulty dimi- nished by the fact that, in most diseases, we can trace a succession or combination of causes. 6tEKEBAL Classification. — The causes of disease have been divided into (1) Predisposing op Semote, (2) ExcUing or Proximate, and (8) Determining. Illustrations will explain what is meant by these terms :— Two individuals are ex- posed to the contagion of typhus in equal degree ; one, wearied by bodily and mental labour, 'catches' the disease— that is to say, his con- dition has predisposed him to the exciting cause of the malady; the other, in vigorous health, escapes the contagion — the exciting cause of disease. Predisposition in fact prepares persons by rendering them more susceptible to the in- fluence of exciting causes of disease. Many per- sons are predisposed to emphysema because of hereditary taint; in them the air they breathe is day by day an exciting cause of this disease ; they contract a bronchitis which, by its attendant cough, determines the malady. Such illustrations might be extended to a multitude of diseases, and justify the division of causes which the older physicians made. Predisposition may be in- herited i or it may be acquired, and be due to various accidental causes. In most cases there is a combination of predisposing causes ; in a man, for example, lowerSd by fatigue, want of food, and exposure, debauch will readily excite an attack of bronchitis or pneumonia. Prac- tically, it is often difficult to say how much is due to predisposition, but, though many factors unite in the predisposition to disease, it is pos- sible in most cases to estimate the part played by each. See Phedisposition to Disease. Moreover it is not always easy to distinguish predisposing from exciting causes. Predispo- sition carried to excess becomes an exciting cause of disease, and in many cases there is a combination of both. There are certain distinct exciting causes — ^for example, heat, cold, or in- juries of various kinds, but most of these can claim a predisposing power. The contagia of the acute specific diseases and parasites are good examples of direct exciting causes. In proceeding to discuss tne subject of .ffitio- logy, no attempt will be made to' separate de- finitely predisposing &6m exciting causes of disease. The writer will endeavour rather to indicate as far as possible under the head of each factor of causation the direction in which it especially acts. I. Age.— This has a most important influence as a predisposing cause of disease. In Wagner's Manual of General Pathology the periods of age are thus subdivided : — (1) Nursing age (infancy)— from birth to 7th- 10th month. (2) Childhood— from 1st to 2nd dentition. (3) Boyhood — ^from 2ud dentition to puberty. (4) Adolescence — ^from puberty to 20th-25th year. (5) Early manhood — ^from 25th to 45th year. («) Later manhood — from 46th to 60th year. (7) Old age— from 60th onwards. • This division is excellent, but in no definition is there more need to look out for exceptions than in that of age. The term age is strictly comparative ; some individuals are old at forty, others young at sixty. Persons fail with regard to particular organs while young in years ; and, on the other hand, others acquire an increased power in the same as years advance, of which the brain aJibrds an apt illustration. The minor organs of the body betray the like peculiari- ties, and in the early decay of the teeth, the changes in the hair and the skin, we meet with indications of old agei though the individuals are young in years. But, generally, the pre- dispositions of the young and old are striking by their contrast. The young are exempt from fatty degenerations, which are so common amongst those of advanced life, and, in conse- quence, many diseases amongst them are, ceierit parilnis, less deadly ; and not only does age, by reason of the changes which naturally occur as life goes on, predispose to disease, but all Oxitward conditions become changed. Children — speaking generally — are apt to suffer from acute catarrhal affections of the mucous tracts, glan- dular diseases," skin-diseases, tuberculosis of acute type, scrofulosis, and a variety of com- plaints traceable to improper feeding, bad ven- tilation, overcrowding, and to hereditary taint From acute tuberculosis the aged are almost en- tirely exempt, and they do not? suffer from here- ditary taint nearly so frequently as the young. The very young and the very old are equally sub- ject to bronchial catarrh, and the mortality from this disease at each extreme of life is exceed- ingly great. But in the young the predisposi- tion to this affection is almost ' invariably asso ciated with a predisposition to catarrh of the intestinal tract, and to diseases which indicate a general constitutional depression ; while in the old bronchial catarrh is predisposed to by a degenerative change in the lungs themselves, or in the air-passages. In childhood there is an active stage of growth and development, and when one important organ is affected the others suffer with extreme rapidity ; the excito-motory system is greatly developed, and hence arises a predisposition to spasmodic diseases — for ex- ample, to laryngismus stridulus, and to general or partial convulsions during the excitement of dentition. In the old the tetideney to spasm decreases, and convulsions become much less marked. Some of the exanthemata, especially measles, scarlatina, and pertussis, are more com- mon amongst children than adults, which is partly explained by the fact that the latter clasp nave passed through the ordeal of those diseases, and are thus proof against them. Kickets also is essentially a disease of infancy and early childhood. The onset of puberty is a constant source of predisposition to disease, for with it comes a complete transformation in the men thiljand physical characters, so that the individual, if not very care- fully watched, deviates from even the most perfect health into a permanent tendency to disease. The system at this period — especially in the case of females — is frequently unable to bear anything which interrupts or interferes with its activity. The generative organs undergo great changes, and with them the whole moral and physical nature is altered. At this period of life there is a predisposition to both bodily and mental dis- eases. In fact, perversions of any organ or faculty may be started, and, once started, they are apt to 384 DISEASE, CAUSES OF. BOntinue , so that there is established, literally speaking, a permanent predisposition to disease, and this predisposition swells Tory largely the list of affections which are dealt with under the generic term Hysteria. Lung-affections — except- ing pure bronchitis — are more common at and shortly after the time of puberty than in previous years ; but, excepting in the instance of phthisis, hereditary taint is less manifested than during childhood. Even hereditary epilepsy is, if post- poned beyond early years, likely to be postponed to the period of adult life. As has been said, the degenerations of organs and tissues begin to show with much uncertainty, but after the fortieth year of life we almost in- variably meet with one or other of them. Their degree and their consequences vary with the sur- roundings of the individual — with his habits, tem- perament, occupation, and likeinfluences. Diseases of the large vessels are especially common at this epoch, such as aneurisms of the'aorta and of the large arterial trunks in the extremities. Hence- forward all the diseases peculiar to advancing age become common. The results of previous disease are now declared by a decided predisposition to exciting causes which have been hitherto with- stood. Old age is a relative term. A man is old and predisposed to trifling excitants because his lungs have lost their elasticity, or his brain its regularity of circulation, or his heart its vigour — in each of these cases, as in a host of others, the predisposition is strictly one of degeneration. Again, inherited diseases do not declare themselves in some cases till the later years of life, and of this car- cinoma is a striking example. The old are pre- disposed to lowering diseases — low pneumonia or bronchitis ; and to a variety of nervous affections which the vigorous can resist. In them the failing heart-power tells a tale ; they are the subjects of general vascular dilatation ; and, in short, they succumb to insignificant exciting causes, because of the general or partial decay of the tissues and textures of the body. 2. Heredity is a prolific source of predis- position. There is amongst men not only an inheritance of such proniinent diseases as phthisis, but of peculiarities in the manner they meet and pass through minor ailments. Thus, in families with a 'nervous history,' we meet with predisposition to headaches of ner- vous type, irregularities of digestion in the form of diarrhcea and vomiting, and a multi- tude of conditions which have of late been ascribed to vaso-motor disturbances. The members of some families live long in spite of exposure to almost every exciting source of mischief, and contrast most favourably with others who, as far as one can determine, have all things in their favour. There is no doubt that the effects of syphilis, malformations, gout, the haemorrhagic diathesis, and tuberculosis are handed down from generation to generation. Of many minor complaints there is less certainty; but it is exceedingly, probable that persons are predisposed to bronchitis and other catarrhs by inheritance. It is acknowledged that epilepsy descends from parent to child, and that, in feet, individuals, because of heredity, are often the subjects of nervous diseases excited by causes which those free from taint are enabled to throw off readily. The various forms of insanity are striking examples. It is supposed that the in- heritance lies in the tissues themselves— that there is a something in the tissue-elements which predisposes to certain diseases in certain families. It has been asserted that there is even a predis- position by inheritance to the acute specific diseases — such as typhoid fever and diphtheria, and some remarkable occurrences in this country strongly bear out this view. 3. Intermarriage. — Intermarriage certainly predisposes to disease, but it is not easy to deter- mine how far its predisposing powers extend, Breeders of first-class animals practise inter- marriage, and thereby develop speed, quality, and endurance in the offspring. It is beyond question that this practice of breeders of race- horses is eminently successful for the time, but it by no means follows th at the permanent results are good. We are bound to look not only to the immediate, but to the ultimate results of intermarriage — in short, to decide whether in termarriages predispose to disease, to the injury of the community. But no rule, free from ex- ception, can be laid down on this subject, for beyond all doubt many intermarriages have led to both physical, moral, and mental advantages. There is no doubt that malformations are handed down, and that where these are marked in families it is injudicious for persons to inte> marry. Where also, for example, serious diseases, such as phthisis, have been met with on botli sides, it is most advisable that intermarriage should not take place. 4, Ses. — There are great differences in the organs and functions of the sexes, and in conse- quence a great contrast in their predisposition to disease. The female is more delicately constructed than the male, and those organs which the two sexes possess in common differ in weight and in 'fineness;' and a general consideration at once indicates that the female is less fitted than the male to resist many exciting causes of disease. This is particularly evident at climacteric periods of life ; with the onset of puberty girls suffer far more than males, and especially from a variety of reflex spasmodic disorders, which require but little provoflation for their develop ment. All the phenomena classed under the head of hysteria often occur at this period. At the same time, and shortly afterwards, there is a tendency to ulcer of the stomach, to persistent constipation, to peculiar attacks of neuralgia — especially of the intercostal nerves, and to acute rheumatism, lapsing into the subacute or chronic kind. Ansemia and chlorosis are also common at the period of puberty, and if then neglected they are apt to persist, and predispose the indi- vidual still more to disease. Even so early as the period of puberty the external circumstances of the sexes differ, and on this depends, in a certain measure, the difference in their predisposition. Education, domestic habits and customs, and, above all, occupation, play an important part. But, under- lying these outside influences, there is inherent in the sexes a difference in predisposition ; fo* when they are exposed, as often happens, to the same surroundings, they suffer from vridely ecpo- DISEASE, CAUSES OF. 38S rated diseases. Males are more subject to epi- lepsy, tetanus, gout, diabetes, locomotor ataxy, vesical diseases, and acute lung-affections, than females. The list shows that occupations which involve hard mental and bodily work and con- stant exposure explain some of the varieties in predisposition. It is probable that females are more freqxiently ailing than males, but very often their illnesses are associated with the menstrual functions, and are trifling in degree, and, though more males are born than females, towards tie later years of life the average of the sexes becomes more equally balanced, because the mortality of males is greater than that of females. It is sufficient to allude to the fact that pregnancy and lying-iu predispose females to diseases from which males are entirely exempt ; and tliat there is a considerable difference in the sexes as. regards venereal affections, both as to predisposition and the effects of that predisposi- tion. 6. Temperament is important as predispos- ing to disease. Persons of sanguine tempera- ment are disposed to congestions of organs, and haemorrhages, on comparatively smallprovocation. Phlegmatic individuals are the subjects of those diseases which are readily excited by want of mental and bodily energy and activity. A third set belong to the nervotis temperament ; they are easily excited and easily depressed, so that excite ants cause either a form of hysteria or hypochon- driasis, for example. The predisposition amongst this class is constantly met with in diseases of an acute character. Nervous persons suffer quickly from delirium and other brain-symptoms, which aggravate and render dangerous an other- wise hopeful malady. In the acute specific diseases this is particularly manifested ; nervous people are undoubtedly predisposed to them, and when once attacked are predisposed to dangerous complications. PracticaJlywe meet with 'mixed' temperaments, though one perhaps especially prevails. See Teicpebaiosnt. 6. Climate and Locality. — These differ widely in their predisposition to disease. Persons who have been accustomed to a particular cli- mate frequently suffer when transferred to one differing from it; and on the other hand the sick often benefit by change. Particular diseases flourish in particular climates, and particular organs suffer. In the tropics various endemic fevers prevail which are unknown in this country, for they cease to exist when the temperature sinks below a certain level (about 60° Pahr.). Frost very often cuts short epidemics in our own country in like manner. Particular organs are predisposed to disease by climate — the liver in the East Indies, the lungs and the kidneys in regions where the temperature is capricious. Climiites differ as regards air — whether moist or dry, hot or cold ; but besides these things the topography must be considered, and the elevation of districts. Plains, mountains, and valleys have various predisposing influences, and while much of such influence depends on the configuration of the country, no little is due to the nature of the soil. No better proof of the latter fact can be given than that yielded by the observa- tions of Dr. Buchanan, who has shown that where I. proper system of drainage of soil- water is carried 25 out, the tendency to pulmonary diseases is very greatly diminished. Olaysoils are cold and damp, and favour diseases aruiised by those combined agencies ; sandy and gravelly soils readily drain themselves, are warm and dry, and thus far tend to protect those who live on them against disease. Climates are also modified by trees, rocks, rivers, lakes, &c. Detritus carried down by streams and deposited along their banks or at their estuaries, has, like ground vegetation and its decay, an un- doubted predisposing influence. Particular dis- tricts also predispose to certain diseases. Cretinism is most common in close valleys ; urinary calculus is endemic in many districts of Great Britain and elsewhere. In some circumscribed areas in Scotland, in Norfolk, and other districts, individuals are especially liable to stone. The influences of climate are well shown by the electric conditions of the atmosphere; some persons are so predisposed that they can foretell a thunderstorm by the change in them- selves. Fogs in large cities depress most people ; and it is not too much to say that many diseases may be traced to a predisposition which 'bad weather ' has started. Alcoholism has been pro- voked in this way. It is clear, therefore, that under the head of climate there are many combin- ing influences, which affect the moral, mental, and bodily nature of individuals, and through one or all may predispose to disease. In this country, and probably elsewhere, those who dwell on mountains are less liable to disease than the dwellers on plains ; marshy plains especially predispose. It should be remembered, however, that it is not climate alone which varies the pre- disposition amongst persons residing in different regions, for their habits, diet, &c., differ far more than the climate in which they dwell, and predisposition to disease should never be ascribed solely to climatic conditions unless accidental influences have been investigated and eliminated.' >Sf8e Climatb. 7. Tovm and Country. — The influences of town and country, as predisposing to disease, re- quire a separate consideration. With them may be considered dwellings, and a variety of minor sources of predisposition. The mortality of coun- try districts is less than that of towns, but towns differ in this respect amongst themselves. The health of the largest city in Great Britain, for ex- ample, compares favourably with any of the large manufacturing towns and with many rural com- munities. It is easyto understand that differences must depend on the occupation, food, and habits of the people, and on their external surroundings — air, light, drainage, and like conditions, In large towns occupations are more lowering than in country districts ; while the physical and men- tal strain is greater, and has fewer interruptions. Late hours, intemperance, and prostitution prevail in towns ; but it is by no means certain that, in proportion to the population, these ills are less frequent in the more remote districts. In towns overcrowding checks ventilation, makes ' Imperfect drainage leads to what are popularly known as ' damp walls ' in dwellings, and thus predisposes to pulmonary diseases by inteatering with ventilation— in fact, by preventing the admission of pure air into such dwellings. This truth bears out the teachings we have derived from Dr. Buchanan's investigations at Ely and elsewhere. 386 DISEASE, CAUSES OF. drainage difficult, so that subsoils become satu- rated, clouds the atmosphere -with smoke and dust, intermingles the seXes (amongst the lower classes) so that succeeding generations are stunted in their development, and in a variety of other ways predisposes to disease. But in some towns these evils have been obviated by sanitary measures, and as a consequence towns often pre- dispose less than country districts to diseases due to defective drainage and overcrowding. Some startling illustrations of this fact have occurred since sanitary science has been acknowledged to be of national importance. In villages, for instance, reputedly ■ model,' epidemics of disease associated with defective drainage and evil domestic arrange- ments have decimated the inhabitants, and the virulence of these epidemics has been greater than that of those met with in large towns. The latter are now-a-days for the most part better drained than country districts ; thus milk-epi- demics of typhoid fever have been imported into large cities from isolated farms where the drain- age alone seemed to be at fault. Amongst children, rickets, scrofula, and tuberculosis are far more prevalent in town than country. The mortality amongst young children is far greater fn towns than country districts. Adulterations are an evil in large communities, affecting people of aU ages. From many of these country districts are free, and especially is this true as regards milk. So while dwellers in the country may have bad drainage and bad houses, they have pure air as a rule, every opportunity of breathing it out of doors, and unadulterated milk. Even the alcoholised drinks in many country districts are home-made and harmless when compared with the adulterated raw spirits taken by the lower classes of large towns. 8. Hygienic Conditions. — One of the most common causes of disease coming under this head is want of cleanliness. To this is due a variety of skin-diseases, such as eczema of the scalp in children, diseases caused by pediculi, &c. It interferes with the functions of the skin generally, and by it even a common cold is modified. Clothing is a part of this subject. Insufficient clothing is a most im- portant source of predisposition, amongst the rich as well as amongst the poor ; for, though the climate of this country is so variable, cor- responding adaptations of dress are for the most part neglected. Flannels worn day and night also predispose to disease. Clothing is used to pre- vent the loss of heat, which occurs in three ways — by radiation, conduction, and evaporation, and a careful adaptation enables us to modify these sources of loss in such a way as to obviate a pre« disposition to disease. There is probably more care taken in tropical climates to regulate the heat of the surface than in the temperate zones. A very common cause of predisposition to disease is neglect of proper bedding. Deficient ventilation and overcrowding are prolific sources of mischief. Overcrowding without ventilation is one of the greatest evils of our chief cities and towns ; and not only is it in their homes and workshops that popu- lations are overcrowded, but in their places of recreation, such as theatres, and in their places of religious worship. Briefly it may be said tliat overcrowding predisposes to moral, mental. and physical deterioration ; to epidemic diseases, and especially to typhus fever; to pulmonary aiiections ; and to a variety of nervous diseases. By lowering the wiorafe of popalatiSns it increases all other predispositions, and, in fact, passes into an active exciting cause of disease. 9. Occupation. — This is a common cause of disease, and is often associated with want of proper hygienic conditions. The overcrowded in work-rooms breathe an impure air, an air loaded with carbonic acid, irritant particles, and various exhalations, and thus are liable to disease. Miners breathe an air laden with carbon j knife- grinders inhale fine particles of metals ; marble- polishers and masons are in the same plight; in all three cases occupation, combined with neglect of hygienic precautions, leads to pulmo- nary diseases. Occupation is in many cases a direct exciting cause of disease; for example, workers in arsenic, antimony, copper, lead, the mineral acids, &c., suffer from the poisonous effects of these substances. Bat oftentimes they escape the direct influences, yet are subjeetlo a predisposition to various diseases, as a couse- quence of their occupation. Various other occu- pations, such as those of tailors, shoemakers, milliners, and brain-workers, predispose to disease in different ways. Too much work and too little work (mental or bodily) predispose distinctly to disease. Con- tinued overwork reduces the system generally, and special organs in particular, according to its nature. A coachman, who uses for many hours his pectoral muscles in driving, suffers chiefly in them when he has an attack of mus- cular rheumatism. So also those who use the brain too much in intellectual work are pre- disposed to functional, and even to organic derangements of the nervous centres. Physicil overwork is often conjoined with exposure and improper or irregular food-supply, and the com- bination has a marked effect. It has so predis- posed armies to disease that their ranks have heen decimated by fevers, pneumonia, and bronchitis, far more than by the cannon or by the sword. Not a few medical men have been affected hj the contagia of the acute specific diseaies, be- cause when exposed to them they were worn out by bodily and mental exertion, and by pro- tracted fasting. Over-work reduces the ner- vous power, and thereby strikes at the very root of the healthy status. On the other hand a sluggish use of the mind and body are favour- able to disease, and some persons are so con- stituted that they cease to be safe when their minds have lost the opportunity of active eiei cise; and the very fact that they substitute an abnormal intellectual employment is proof of this truth. And what is true of the mind is true of the body. A sudden change from_ active bodily exercise to bodily laziness predisposes largely to disease. 10. . Air. — The question of air has aheady been alluded to, in considering climate, occupation, town and country, overcrowding, &c., and it is scarcely necessary to dwell much more on ite aetiological effects. Air influences the predisposi- tion to disease according to its degree of rarefac- tion, moisture or dryness, warmth or coldness, and the impurities, mechanical or chemical, which iuay adulterate it. In ths article Cumatb many of these atmospheric conditions are fully dwelt apon.and their tendencies explained. Impurities in the ait are exceedingly prevalent; and mechanical substances suspended in it can excite irritable conditions qf the _ air-passages which may pass on to inflammation, and even destruction of the lungs. Throat and laryn- geal affections are a comnion consequence of these impurities. All these chiefly occur amongst certain dasses whose occupation loads the. air with fine particles as already described. There s scarcely a mineral used in the arts which cannot, by inhalation, pxclte^ or predisjjbse to disease. The air may also he rendered impure by chemical agencies, and the, moment the normal proportion of its elements is disturbed it becomes a source of disease, Excess of car- bonic acid is especially an element of mischief — causing headache, dyspepsia, and nervous depression. The presence of ammonia and of sulphuretted hydrogen is attended; by Jike results. The human economy iS( however, so framed that its organs can often very rapidly throw off the evil effects of these gases when breathed in overcrowded rooms, &c., so that no permanent mischief is established. Poisoned air plays a part in the production of scrofula, anffimia, and lowered conditions gener- ally; but it is an incomplete comprehension of the causes of these conditions to set down all to this one. The air, also, may be poisoned by other gases, such as earburetted hyi;ogen. The atmosphere is modified by currents — sometimes to the relief, sometimes to the danger of mankind. Winds can remove sources of con- tagion — they can ' clear the air.' But they can also bring contagion into localities accor(^g. to many authorities. Cholera and other diseases have, it is said, followed aerial currents — that, is, h?,ve been carried by them. East winds , are a prolific cause of disease ; tliey excite it directly, and carry off healthy individualB, even though the cold be not extreme. Sometimes westerly winds have a dangerous influence, and. in the winter of 1877-1878 a wave of disease, having many of the characteristics of 'influenza*, was carried across England by a west wind. 11. Previous Disease. — Previous disease often predisposes to the same or to some other affection, and no clinical history is . of value unless it includes a? account of former ill- nesses. In d.i£&cult and doubtful cases a true statement of these often gives the clue to diag- nosis, and even patients themselves are alive to the value set upon an accurate account, of their life-ailments. An attack ,oj. croupous pneumonia predispos,es to rec^irrencp, especially during the twelve months succeeding the.attack; and it may leave behind a predisposition ex- tending far bejrqnd the original dis.ease, Choreai acute rheumatisSi, tonsillitis, and ^epilepsy tend to recur, as also do the ordinary convulsions of chil- dren ; but in all these and many qtlier cases it is difficult to estimate the exact part played by derived predisposition, because ^n .all the primary predisposition may be the main agent in , the subsequent attacks. Ifl jpractipal medicine it is distinctly recognised , that ceiT tain diseases predispose to disease, and i^ DISEASE, CAUSES OF. 3S; their case recurrence is, very properly, jealously guarded against. Pertussis is supposed to pre- dispose to measles, and viae versa. There is distinctly a connection between chorea,_ rheu- matism, and scarlet fever, and these diseases may follow one another in anjr order. Again, previous disease may leave behind pathological lesions •which remain in abeyance until excited by causes which the healthy individual could readily withstand. Pertussis often ends to all ap- pearances favourably, but afterwards the patienta may suffer from severe lung-affections, upon tri- fling exposure to exciting influences. Calcareous deposits in the lupgs may excite a new catarrhal phthisis ; hepatic mischief followed by collection of gall-stones in the gall-bladder may cause peritonitis and other diseases. Slight complaint^ ate even more marked in their predisposing powers than serious diseases. On the other hand, previous disease sometimes protects individuals and communities ; fo; example, vaccination can save nations from the most terrible of scourges. In the case of scarlet fever, typhus, pertussis, merles, &c., an almost perfect immunity is ac- quired hy those who have already suffered from them. Of course, as with small-pox, no one denies that second attacks of these diseases do occur, but such attacks are ■wholly exceptional. 12. mental and Moral Conditions. — Bad news may cause sudden death, or, short of this, may interfere mth the functions of par- ticular organs. Sudden mental -worry may excite dangerous interference with digestion, or start an abnormal cardiac rhythm.,. Erighthas turned the hair .white within a few days or hours in healthy persons. Mental and moral shock can check or increase the flow of urine,, and, in fact, can affect all the excreting and secretr ing organs of the economy. Mental overwork ,can excite, per se, brain-conditions of a dangerous nature, such as hypersemia or anjemia,j and even, it is said,, meningitis of simple or tubercular form, according to the inherited predisposition. Undue or sudden emotional disturbances can ex- cite s^ious mischief, just as they can predispose to it. Again, the mind is affected by imitative influen^ces ; thus chorea is excited in some indi- viduals by watching choreic movements, and a single . hysterical patient may arouse in others symptoms, almost identical with her own. Tho sul^ect of the direct influence of the mental and inoral state pn disease is, however, too wide to be here dweltupon. J?. External FhysicalOonditlonB. — These a,ce very numerous as exciting causes of disease, yiolenfe over-exertion can cause hemise, hsemor-r rhages, as from the vessels of the lungs, cerebral congestions, and even ruptures of the valves of the heart, and in one or all of these cases lead directly to death. Over-exertion with the voice may .be followed by pharyngitis or laryngitis. Syncope has occurred in the most healthy from violent exertion in hill-climbing, in boat-racing, walking and running .matches, &c.,. acute dila- tation of the ventricles probably occurring. Various forms of direct injury are frequent causes of disease, 14. Foisons, — Poisonous gases are powerful excitants of disease, and so are poisons generally, whether animal, vegetable, or inorganic. They 388 DISEASE, CAUSES OF. may kill quickly or excite a disease of long- continued or even permanent nature. 15. Temperature. — Heat and cold carried to excess may prove fatal at once. The influences of severe cold are desorited undei the heading COLD, and it is only with the diseases excited ty heat and cold in the everyday acceptation of these terms that we shall deal here. Long-con- tinued heat lowers the vital powers, and may excite such diseases as slight eczema of a simple character, or such grave affections as in- flammation of the membranes of the brain. Heat may kill suddenly, as in sun-stroke, or excite cerebral mischief just short of death; while in persons of tubercular diathesis it may induce tubercular meningitis; and even more gfeueral effects follow severe local applications of heat. Hoderate heat applied to the back often de- presses the heart even to syncope. Choleraic attacks in this country usually are associated with exposure to immoderate heat. Cold is the most common cause of disease in temperate climates, especially in the changeable climate of this country. It can excite disease directly, and can affect probably all the organs of the body, causing either disturbed function or organic mischief. Cold, when severe, contracts the vessels ; interferes with the circu- lation, and all vital activity; and in this way may cause death. But it is with moderate degrees of cold we have chiefly to deal. A momentary exposure to a cold draught is as frequent an excitant of disease as general ex- posure for a long time. A cold draught playing on the cheek may cause facial paralysis, sore throat, or bronchitis ; that is to say, cold applied locally may excite disease in the neighbourhood of its application or in distant organs. It is piobable, therefore, that cold may act in several ways : (1) it may interfere with circulation ; (2) it may affect the extremities of ■ nerves and excite disease by reflex action ; or (3) it may check secretions of the skin, the mucous mem- branes. &c. We cannot wonder, therefore, that diseases of the throat, larynx, and lungs are frequently ex- cited by cold. Bronchitis and pneumonia are its most common results ; and as the young and the old are less enduring of cold than adults, it carries them off with great frequency. Piarrhcea, renal diseases, congestion of the liver, acute and chronic rheumatism, simple dyspepsia, and a host of other affections, are traceable in many instances to cold. Predisposition has much to do with the effects of cold ; some in- dividuals suffer from one form of disease when exposed to it, others from entirely different affections. In some, 'a common cold' is most evidenced by severe muscular pains and fever, in others by a nasal discharge, in others by head- ache, and so on. Some persons never suffer from ' cold ' without having an attack of ierpes labialie; and numerous similar idiosyncrasies might be given. The effects of cold should always bo considered with almost all predispos- ing causes of disease. 'Cold' is a vague term and not thoroughly understood ; there is all the more reason why, when it comes under consideration in individual cases, its -precise effects should be most carefully considered and recorded. DISEASE, CLASSIFICATION OF. 16. Diet. — Food and drink can by their abuse excite disease, and gluttony is as powerfdl an excitant as drunkenness, though in temper- ance outcries this fact is almost completely lost sight of. Excess of food does not refer simply to the quantity taken, but to its quality— its nature, richness, and the times when it is taken. Agricultural labourers eat more than the gentry, but live longer, and the gentry of old-fashioned type are longer-UTed than whose who frequent the fashionable world. Excess of food overloads the stomach, makes calls upon it which it cannot meet, and dyspepsia is the result. Excess of food, if digested, charges the blood with materials not demanded by the economy, and disease of excre- tory organs or fatty degenerations may this is excited. Want of food also excites disease, such as pneumonia, bronchitis, or other catarrh, espe- cially in children, many deaths amongst whom are the direct consequence of improper feeding, When the proper admixture of the element! of food is neglected, disease results, as, e.j,, scurvy. Particular foods will immediately ex- cite violent gastric catarrhs in some individuals, while others can bear them perfectly well. Putrid food is an active poison. Certain kinds of fish are poisonous in themselves, and some vegetable foods laden with salts of lime are supposed to csuue urinary calculi. Water" and milk are prolific sources of mischief, through the impurities they 80 often contain. The drinking waters of large towns are usually derived from rivers, and fil- tration is not a sufiScient purification, so that disease may be excited by their use. Alcohol is a most extensive source of disease : it causes, when taken in excess, cerebral, gastric, intes- tinal, hepatic, and renal affections, and can lower the system so far as to predispose to other dis- eases. See Alcoholism; and Poisonods Food, 17. Spidemio Diseases, Contagion, Hals- ria. Parasites, and Growths are treated of under separate headings. It is now generally es- tablished that the diseases known as the acute specific diseases are mostly direct consequences of some contagium. So among the most common exciting causes of disease we must class the contsgia of the several fevers, of syphilis, &o. See P^soNAL Health ; and Pcblic Health, J. Peaesok Ibvike. disease:, Classification of. — Various classifications of diseases, or systems of .nosology, have been adopted by different vraiters, but it is beyond the province of this work to discuss these arrangements, neither of which fulfils all that is required, or can be regarded as satisfactory. All that can be done here is to point out the characters upon which the chief divisions of diseases are founded. The first classification deserving of .mention is that into (1) General and (2) Ijocal. Gen«- 1 ral diseases include those in which the whole system is involved from the commencement, and it comprehends as sub-divisions {a) The acute apecifio fevers, and certain other diseases due to the introduction of some morbific agent into the body from without, or in some instances developed within the system, for example, typhus and typhoid fevers, scarlatina, small-pox, malarial fevers, hylirophobia, sypiih* BISEASE, CLASSIFICATION Of. pyaemia and aepticsemia. (i) The so-ealled vonstiiutionai, cachectic, diathetic, or blood- diseases, some of whioli seem to depend upon the production of deleterious elements within the system, Trhich are capable of recognition, such as rheumatism and gout; ■while others aie independent of any audi, obvious patholo- gical causes, but are supposed to be severally associated with a peculiar dyscrasia or diathesis, for instance, cancer, tuberculosis, scurvy, rickets. Local diseases ate those which primarily affect particular organs or tissues, each being liable ;o its own peculiar lesions. Thus we have diseases of the lungs, heart, stomach, liver, kid- neys, brain, and the other organs ; of the mucous membranes, serous or fibro-serous membranes, skin, periosteum, bone, and other structures. This division into general and local diseases is useful within proper limits, but it must be re- membered that general maladies are often re- vealed or accompanied by local lesions, and that complaints which are originally local often more or less speedily set up general disturbance. More- over, it is still a question whether some maladies are to be regarded as general or local in the first instance. See Sykmetky in Disease. Another division of diseases, which applies more particularly to those which are of a local nature, is into (I) Organic or Structural, and (2) functional. These terms are self-ex- planatory, the former implying that there is 9ome organic change in the affected part, which we can discover and demonstrate ; the latter indicating that there is mere functional disorder, which is independent of any recognis- able lesion. That there are structural changes in many affections which are regarded as func- tional is, however, highly probable, though our means of observation are not sufficiently powerful to enable us to detect them. In con- nection with each organ, a special classification of its individual complaints under one or other of these primary headings is usually adopted, this sub-division depending upon the affections to which the particular organ is liable. As illustrations of functional disorders may be men- tioned disturbed action of certain organs, >as of the heart, causing palpitation ; derangement of the secretory or excretory functions, as in the case of the stomach, liver, or kidneys ; and many nervous disorders. Organic diseases are exem- plified by inflammation and its consequences; alterations in growth and development; degene- rations ; malformations ; and new growths. In this work it has not been deemed advisable to describe the diseases of the several organs ac- cording to any definite scientific arrangement, but in some cases an alphabetical order has been adopted, while in others individual writers have been allowed to classify the affections of a par- ticular organ according to their own judgment. Again, diseases may be classified according to their causation and mode of origin. Thus they are divided into(l) Hereditary, or those which are transmittW either directly from parents to children, or indirectly, as the result of a family taint ; and (2) Acquired, or those which are developed anew in persons free from hereditary taint. When a morbid condition exists at birth, it is said to be Congenital. Other divisions. DISEASE, DIAGNOSIS OF. 389 founded on an setiologioal basis, are into (1) Oontagioua or Infaotious, and (2) Non- contagious; and into (1) Bpeoiflo, or those diseases which are due to a specific cause, and (2) Hon-specific. There are other classifications of diseases. which need only be mentioned here. Thus, ac- cording to their intensity and duration, they are said to be (1) Acute ; (2) Sub-aouta ; or (3) Ohronio. Another arrangement, founded on their mode of progress, is into (1) Continuous ; (2) Periodical, or affections which come on at more or less definite intervals ; (3) Farozysmal, or those which are characterised by sudden or acute paroxysms ; and (4) Beourrent, or diseases which tend to recur. _ Lastly, according to their mode of distribution amongst communities or in districts, complaints are said to be (1) Sporadic ; (2) Spidemio ; (3) Kndemic ; and (4) Pandemic. The meanings of these terms are defimed under their several headings, but they are sufficiently familiar as indicating the mode of distribution of the diseases to which they respectively belong, With regard to the classification of diseases which is likely to be permanently adopted in the future for general use, it is probable that this will be founded on a pathological basis, and that, as our knowledge of morbid conditions and pro- cesses becomes more extensive, accurate, and definite, it may become possible to establish a system of nosology which will be both scientific and practically useful. 1 Feederick T. Eobeets. DISEASE, Diagnosis of (Sick-, intens., and yui^cTKio, I know). — Stnon. : Fr. Diagnose; Ger. der Diagnose. DBFiNrrioN. — ^Diagnosis is the art of recog- nising the presence of disease, and of distinguish- ing different di seases from each other. The term is also applied to the result obtained. ■ General Considerations. — The general prin- ciples only of diagnosis will be here discussed. Spectai diagnoses will be treated of in connec- tion with the several diseases to which they have reference. In many respects diagnosis is a subject of great interest and importance. First, in a scien- tific point of view, it is essential that all knosv- ledge should be accurate. Secondly, accuracy of diagnosis, founded upon a sound pathology, en- ables us to frame a scientific classification of disease in its diverse forms. It is also by accu- rate determination of the nature of the disease which may be present in any given case that we are able to anticipate its course, and to employ the right kind of remedies in its treatment. It is imperfection of diagnosis which leads in many instances to an under-estimate of the value of therapeutical agents ; for when the nature of a disease is mistaken we are led to employ im- proper and unsuitable remedies, the failure of which is then erroneously attributed to the inefficiency of the agents, and not to the unfitness of the treatment employed. If our diagnosis had been correct or complete; the remedy selected would more often have had the desired effect. , la order to arrive at a diagnosis we m-ust study the phenomena or characters of each in- 890 DISEASE, DIAGNOSIS OF. dividual ease, and trace its connexion Tfith tiiose groups of symptoms which have been pre- viously recognised and described as belonging to special or distinct diseases. Assuming that the classification has been already made, we pro- ceed to deal with the means which enable ns to identify each individual case, and to connect it vnth a previously classified disease. Means op Diaqnosis. — ^To obtain accuracy in diagnosis we must be prepared with a know- ledge of the several forms and varieties of disease ; we must be familiar also with the functions and structure of the several organs of the body in health. It ia by observing and comparing the changes caused by disease in the these functions and structures, that we are en- abled to discover the presence of, and to deter- mine the nature of disease. In forming, then, a diagnosis in any; particular case, thaphysician must, as far as possible, keep in view the real or the ideal condition of the patient in a state of health. Ho must endeavour to place him in as natural a position as may be, and as little disturbed by the presence of his attendant, or by external circumstances, as possible. The phy- sician must then obtain a history from the patient himself or from others of the incidence of the disease ; and having done this he must proceed to investigatefor himself tbecondition of tbepatient. 1. Previoits history of the patient. — ^The history implies of course a statement of the age and sex of the patient, as well as of his home and his em- ployment — each of which may have a special rela- tion to disease. It should also include an inquiry into the antecedent generations of the patient, and how far he may have any proclivity to con- genital disease or malformation. This inquiry should have reference to both positive and nega- tive facts. It should extend not only to the previous existence of disease in the family, but also to the absence of particular diseases or types of constitution. The patient's history should include a statement as regards the diseases and injuries from which he may previously have suffered ; the remedies used for them ; and the climatic and other infiuences to which he has been exposed. Nor must the physician neglect to ascertain the history of any children that the patient may have had, as the nature of disease from which the offspring have suffered in many instances throws light upon the health of the parent, 2. History of present illness. — The history of the present illness should include the determina.t tion of the date of its commencement ; its probable cause ; and its progress as influenced by external circumstances, including treatment. 3. rfe present condition of the patient. — Here we have to deal with two classes of phenomena ; namely (o) those feelings or facts of self-con- sciousness which the patient describes to us — subjective phenomena ; and (J) those signs which we ourselves observe — objective phmiomena. a. Subjective phenomena. — ^Thepatientdescribes to us his feelings — as of strength or weakness, of numbness, tingling or pain, of wakefulness or wandering ; he can tell of affections of vision, of hearing, of smell, or of taste ; of breathlessness, cough, palpitation, or of feelings of sinking or fointness ; of difficulty of swallowing, thirst, loss of appetite, nausea or sickness, or various senesr tions and actions connected with the abdomen • of feelings associated with the genito-urinaiy organs, euch as pain or difSculty in passing water ; of cramps, spasms, or other alterations of sensa- tion or motility; or of disturbances of sensibility and activity, &c. Each of these signs of deviation from health will have its ovra value and signi- ficance. The physician must at the same time carefully note how far the condition of the pa- tient is in accordance with his statements, and whether there may not be present some reason or cause for concealment or exaggeration. 4. Objective phenomena. In studyjng.ithe ob- jective phenomena connected with disease^ the physician makes use of his special senses, assisted by the several instruments with which modem science has provided him. i. First, in matters of et/e-sigiht,h6 sees the general aspect and expression of the patient, which will include the colour of the skin (such as may result from the fulness or emptiness ot the blood-vessels, from the yellowneiss- caused hy jaundice, from the blueuess of cyanosis, or from pigmentation, &e.) ; the presence and character of cutaneous eruptions (especially in the exan- themata) ; the expression proper, such as that of case or suffering, and of depression, or excite- ment ; the conditions of obesity and plethora, or of wasting and bloodlessness. He will also ob- serve the position of the patient, how,heJies, or sits, or stands, and hoir breathes ; the appearance of the eyes, the tongue, etc. Further, the sense of sight will be employed in determining conditions of a local or less general nature. lObservation must be made of the size, the shape,.and move- ments of parts, and of their e^ansion or con- traction. With- the aid of special instruments, such as the ophthalmoscope, the laryngoscope, the various specula, sounds, &c., the physician will be able to examine parts of the body of the patient, beyond the reach of the unassisted eye. The chest-measurer or the stethometer will render more exact the information already obtained by the eye ana hand as to the size and mobility of parts. The us e of each of the several instruments above mentioned, as a means of diagnosis, Till be found described under the heads of thoir-ie- spective names, or in the article on Phtsicai EXAMIKATION. The sense of hearing tells of the character of the breathing, the voice, and speech of the patient, including cough, hoarseness or aphonia, ' aphasia,' &c. But the ear is especially applied to the study by auscultation of the sounds produced in con- nexion with the heart, the lungs, and other or- gans. The signs thus elicited will be found fully described elsewhere. The sense of totich or feeling will communi- cate a knowledge of the temperature, of moisture or dryness, of size, shape, elevation or depression, of smoothness or roughness, of the pulse or pul- sation, vibration, fremitus, of extent of move- ment, resistance, softness or hardness, and of fluctuation. The accuracy of the results of these observations by touch may be tested by the use of the thermometer, the calipers, and the tape- measure. The sense of sTnell aids diagnosis in certain cases. The general odour of the patient may DISEASE, DIAGNOSIS OF. be observed in small-pox, in rheumatism, and some -wasting diseases (such as phthisis), and in syphilis ; and the odour of particular parts and secretions, as the urine in di'abetes,_ and in cases of the use of certain drugs, or in poisoning. In- formation is also afforded by the odour of certain discharges, as in ozsena, leuoorrhoea, cancer, &c. The sense of taste is seldom employed in clinical investigation, but the physicianmaymake use of the patient's taste, as in tasting the urine in diabetes. Fmtker aids in Diagmsii). — Having thus sum- marily described the employment of the special senses in' diagnosis and given examples of their use, we may briefly mention some other agencies of more general application. The aoutenesp of the patient's sense of touch may be determined by the ffisthesiometer ; the capacity of the lungs may bo measured by the spirometer, and the strength of muscles by the dynamometer; the contractility of muscles by galvanism; the force and character of the pulse are determined by the sphygmograph; constant use is found for the microscope, the test-tube, the spectroscope, and polariscope, which aid in determining the character of the various secretions or morbid matters that require to be submitted to inves- tigation. The result of treatment may also be mentioned as an aid to diagnosis, as for example, when an indurated sore yields to the use of mer- cury. Again, the knowledge that a person has been in a malarious district enables us to decide on the intermittent nature of certain symptoms that may be present. In some cases it may be necessary to render a patient insensible by anaes- thetics, with a view to making a complete ex- amination, or in investigating feigned diseases. The administration of small doses of charcoal has been suggested as a means of determining the presence of a passage through the bowels when more or less obstruction exists. Such then are the means used for taking note of those deviations from health which occur in the several functions and structures of the body, and which constitute what are known as the Sf/mptoms and Signs of Disease; these are terms which will be found more specially treated of under the heads Disease, Symptoms and Signs of ; and Physical Exauination. The DippiCDiTiEs of Diagnosis. — It needs scarcely be said here that the practice of diag- nosis 'is not free from great difficulties. We know how hard it is to obtain in ordinary daily life a reliable account or description of any past or present event. There must be still greater difficulty in obtaining an accurate medical history of a patient's case. He has to tell of facts of which practically he may know much, but soien- tifically very little. He may be forgetful or ignorant on points about which we most need to be informed. He may bo inclined to ex- aggerate or to suppress facts of material import. Nor are the difficulties less in regard to the objective phenomena with which we have to deal. The symptoms of. a disease are rarely so clear and definite as to mark its nature, that is, to be pathognomonic. They are more often slight, undefined, obscure, and to be found with diffi- culty. The symptoms of one disease may very closely resemble those of another, whilst those 39i of the same disease will vary at different stages, and in different individuals. Again, the symp- toms of a disease may bo complicated by the co-existence of those of another disease ; "srhilst a symptom sufficiently striking in itself may be common to, and present in several different diseases. We need only mention, for example, feverishness, pain, cough, breathlessness, and blood-spitting. These are some of the difficulties which he who has to study the operation of disease in life, has to contend with. He must come prepared for the duty with a knowledge, as we have already said, of the body, its structure and functions ia health, and with a knowledge too of those com- binations of morbid actions which constitute special forms of disease. For as regards this latter knowledge, all the observations made would remain as isolated phenomena if they could not in each case be grouped as constituting distinct diseases. We have thus indicated the difficulties of obtaining accurate knowledge as regards both the subjective and objective phenomena. The difficulties are not less when the exercise of the intellectual and reasoningfacnlties is called upon to analyse, to compare, and to group these pheno- mena. The physician may commence his inquiry by tracing up the history of the case and its several incidents, a method which is called the synthetical ; or he may commence by ascertaining the present condition of the patient, and going as it were backwards in his inquiry — a method which is known as the anaiytieal. As a general rule, both methods are combined in the practice of diagnosis. Observers can sometimes arrive at a direct diagnosis, aided by the presence of some charac- teristic symptom or sign of disease. When diseases which are essentially different have symptoms more or less common to both, the physician will have to institute a comparison between them, until he finds sufficient evidence, in the presence or in the absence of some dis- tinctive symptom or sign, to satisfy him as to the nature of the disease which is present. By being able thus to trace the absence or the presence of a given symptom, he may be able to exclude the possibility of the existence of one or other of the diseases under investigation. These modes of investigation will be found fully illustrated in the diagnosis of the several dis- eases described throughout the work. In conclusion, it must be remembered that these investigations, which call for the exercise of the highest mental faculties, should be conducted without prejudice and without haste. We should never be ready to accept as clear that which is obscure, as established that which is open to question : above aU we should remem- ber that, though to err is human, it is our duty to endeavour to ascertain in each and every case, before commencing its treatment, what its real nature is, as far as it may be possible for us to do BO. It cannot be too often repeated that the application of a right remedy depends on an accurate diagnosis, and that the prevention and the cure of disease are the aims and xUtimate objects of our science. E. Qtjain, M.D. J92 DISEASE, DUEATION OE. DISEASE!, Duration of.— The duration of a disease signifies the period -which elapses be- tween its onset and its termination, in whatever way this may take place. In some instances disease can hardly be said to have any duration, a sudden lesion occurring, which instantaneously, or in a very short time, destroys life; under such circumstances, however, some previous disease has usually existed, though perhaps without giving any clinical evidence of its presence, which determines the occurrence of the sudden result. This may be illustrated by some cases of apoplexy, and of rupture of the heart or of an aneurism. Most affections, as regards their duration, come under one of the three categories already referred to under the classification of diseases, namely, acute, sub-acute, or chronic, but it does not serve any useful purpose to fix any definite limit of time as specially expressed by each of these terms. See Aodte, and Chhonic. Acute diseases are of limited duration, and in many of them this is remarkably uniform, as may be illustrated by the acute specific fevers and acute idiopathic pneumonia. Even m such affections, however, there are deviations from the ordinary course, instances occurring in which the duration is longer or shorter than that usually observed, and this fact de- pends on various circumstances, of which the most obvious are the intensity of the disease in any particular case, the previous condition and surrounding circumstances of the patient, the occurrence of complications, and the treatment adopted. Complaints which are sub-acute as regards their duration may be exemplified by many cases of whooping-cough and chorea, and by some cases of pleurisy, phthisis, pneumonia, gastric or enteric catarrh, and certain skin-affec- tions. A large number of diseases are chronic in their duration, and many of these when once established become permanent, whilst others are ultimately capable of being cured. As illustra- tions may be mentioned organic diseases of the heart, most cases of phthisis, cirrhosis of the liver, chronic Bright's disease, dyspepsia, many skin- affections, and also morbid growths in various structures. Some complaints, as regards their duiation, can only belong to one or other of the groups just indicated, but a considerable proportion may in different cases be either acute, sub-acute, or chronic. Again it must be borne in mind that a disease may be acute or even sudden in its origin.but afterwards may subside into a chronic malady. Certain affections are chronic as regards their entire duration, but are characterised by the occurrence at regular or irregular intervals of acute or even sudden attacks, lasting a more or less definite time, which course of events is exemplified by cases of ague, epilepsy, and asthma. Fbbdeeick T. Robeets. DMEASB, Germs of. — See Gehms of Disease. DISEASE, Prognosis of {irph, before, and yif(i , rarely acute, such asweseein tubercular diseases of the lungs, render the patient more or less an invalid so long as he lives, and generally end fatally. The like observation will apply , to the so-called m.lSlNF£CTION. served in its clinical history. Thus, accordinjf to the intensity of the symptoms and their dura- tion, a large number of complaints are, as haa already been pointed out, divided into acute, sub- acute, andchronic varieties. Again, many diseases while presenting in the majority of cases a cer- tain group of symptoms, upon which their general clinical description is founded, exhibit striking differences in the exact nature of the phenomena observed, as well as :e their gravity, when the mass of cases is tfcKen into account, and on these differences varieties or types are founded. This is well exemplified by some of the acute spe- cific fevers, such as typhoid fever, scarlatina, measles, and small-pox. Of these affections several varieties are described, dependent upon the severity of the symptoms, the nature of thosa which are most prominent, or the characters of the eruption. In the next place, the classification of a disease into varieties may be founded upon a pathological basis. For instance, pulmonary phthisis may arise from different morbid processes, and many atteinpts have been made to arrange the cases of this disease into corresponding groups. Illustrations of these patljological varieties are also found in the different forms of cancer; varieties of pneu- monia, of laryngitis, and of fatty disease of the heart ; and in the classification of serous inflammations according to their morbidproducts, such as fibrinous, serous, purulent, &c. Again, such a pathological condition as dropsy or fever may be divided into varieties. Thus dropsy is ar- ranged according to its situation and distribution, as anasarca, ascites, &0.; or according to its pathological cause, whether cardiac, pulmonary, hepatic, &c. Fever is recognised as having seve- ral important types, founded upon its intensity, its course, and the exact nature of the phenomena accompanying the pyrexial state. Another division of a disease into varieties is tstiologiccU, the cases being grouped accord- < ing to their causation, either the immediate pathological or the more remote exciting causes being employed as the basis of division. Thns we have the different forms of meningitis (simple, tubercular, rheumatic, &c.) ; the setio- logical varieties of pleurisy or peritonitis (idiopathic, traumatic, perforative, tubercular, secondary, &c.) ; those of joint-inflammation, (simple, rheumatic, gouty, scrcrfalous, &c.); or those _ of intestinal obstruction. JEtiological varieties are often at the same time charac- terised by differences in the pathological results and products. Lastly, it must be mentioned that sometimes a certain group of symptomi'is summed up for convenience under some single term, which symptoms really depend upon very different morbid conditions and causes; and. therefore it often becomes necessary to classify affections thus named into, varieties. Dyspepsia, neuralgia, apoplexy, epilepsy, and paralysis will afford illustrations of such an arrangement. Feedbeick T. Eobekts. DISINFECTANTS. See DisiNFEcnos. DISIWPBCTIOBr.— Synow. : Tr.JDisinfat- tion ; Ger. Desinfioiren, DEPiNiTioif. — ^Disinfection, in the proper sense DISINFECTION. 397 of the term, means auy process by -which the contagium of a given disease may be destroyed or be rendered inert. . Disinfectants, hoTrever, are used in practice for several objects, and in consequence the term has often been vaguely applied to the use of heat or chemical means for preventing the gene- ration or for the destruction of noxious agents, whether products of specific disease or not. In this vague and erroneous sense disinfectants have been confounded with deodorants, which merely cover or destroy offensive odours without affect- ing the contagia; and with (mtieeptias, which ' are fatal to the growth and multiplication of microzymes.' Following the line indicated by Dr. Baxter in his valuable report on an experi- mental study of certain disinfectants, it is neces- sary to distinguish— 1. The true meaning of the word — that of acting on the specific poisons of communicable diseases in such a way as prevents their ' 2. That of acting upon organic substances in such a way as renders them less liable to undergo molecular change and decomposition, whether spontaneously or under the influence of catalytic agents, as in the case of emulsiu upon amygdalin, or under the influence of living or- ganisms, such as are connected with fermenta- tion and putre&ction. Examples of this kind of action are seen in salting meat, and in preserving small animals in weak solutions of carbolic acid. 3. That of preventing or arresting deoompop sition by killing the torulae associated with fer- mentation in slightly acid media, or the bacteroid organisms associated with putrefaction in neutral or alkaline media. Properly speaking, this is the action of an antiseptic, but the relative power of disinfectants has been largely estimated by their efficacy in this reispect, partly, no doubt, because antiseptic power is desirable in a dis- infectant, but chiefly because it is so difficult to submit disinfectants to their proper test by ex- perimenting upon contagium. 4. That of the destruction of the aioxioiis pro- ducts of the metabolism of dead organic matter, however brought about. These products consist chiefly of gases or vapours, many of which, such as sulphuretted hydrogen, ammonia, and sulphide of ammonium, are easily destroyed by appro- priate agents, even when used in a very dilute state, and success in this respect is no proof of the value of a disinfectant in its true sense, though the power of destroying such emanations is possessed by almost all disinfectants of prac- tical utility. .! . Mode of Actiqh. — The manner in which dis- infectants are supposed to act is very various. Some, such as permanganate of potassium, ozone, and oxygen, set free from water by chlorine, oxir dise organic matter. Others, such as sulphurous acid, withdraw oxygen, and have a reducing influence; or, like chlorine, may combine with hydrogen and remove it, or form substitution- compounds. Those of a fourth class, such as chlorideof zinc and some other metallic salts, are supposed to owe their activity to the power which they possess of coagulating albumen or combining with it. Another class, of which carbolic acid is the type, is supposed to arrest molecular changes, whether they be those neces- sary for vital manifestations or for decompo- sitions. And finally, the mineral acids are supposed to be efficacious, in part, at least, be- cause they alter the reaction of the media con- taining contagia. Most disinfectants act in several of these ways. GmreBAi. Kemaeks. — It has- been proved that the contagia of several diseases must consist of minute, solid particles, for they are neither soluble, nor diffusible, nor volatile, and we may infer that all other contagia are particulate likewise. A characteristic of contagium, due to its particulate nature, is that dilution lessens the chance of infection, but has little effect upou the case if the disease be taken. There is either no effect at all, or a full specific effect. Con- tagi-um particles are apt to exist as clouds in air, water, ■ or milk, instead of being equally distributed throughout; and this bears upon practical disinfection. The particulate and non- gaseous form of contagium floating in the atmosphere prevents it from being absorbed by any liquid or solid disinfectant which does not wash or come into intimate contact -with every portion of the air, and as this is impracti- cable, infected air can only be puWfied by gaseous disinfectants, such as sulphorous acid or chlo- rine. Disinfectants of this kind, to be effective, must be present in such a quantity as is incom- patible with the existence of human beings.' From this it follows that saucers of disinfecting fluids, or irritating -vapours and gases in the sick-room, are merely a useless annoyance to the patient, except in so far as they may be desired as deodoirants. The best method for dealing -with infected air is to replace it by ven- tilation, especially by means of ventilating open fire-places. The proper use of volatile disin- fectants is the purification of walls, ceilings, and inaccessible places ; and for this purpose, if pos- sible, enough should be used to saturate the atmosphere, remembering that the virulent par- ticles are most likely protected by being buried in a bit of epithelium or surrounded by an albu- minous envelope. The nature of the medium in which contagious particles are isuspended has the most important bearing upon the selection of a disinfectant. The presence of albumen is found to protect septic germs to a considerable extent against the action of permanganate of potassium and chlorine, but has little or no influence upon the action of sul- phurous acid and Kirbolic acid. Dr. Baxter gives reasons for believing that the comparatively uniform quantitative action of carbolic acid upon contagia and septic microzymes, as compared with the striking differences between the disinfectant action of chlorine and permanganate upon con- tagia on the one hand and septic microzymes on ' Though disinfectant or antiseptic gases of such strength as can he tolerated in the sick-ioom are utterly inept as regards useful effect upon contagium, it is just possible that they may he of service in destroying or ren- dering incapable of change the organic matters evolved from the skin and lungs, which are always very noxious, and may be especially so in disease. These organic mat- ters are necessarily more or less re-breathed unless the patient he placed in a current of air. If ventilation suffi- cient to prevent all odour cannot be provided, then some gas, such as chlorine or ozone, that will destroy the caoBt of the odonr is certainly desirable. 398 the other, is chiefly or entirely due to differ-i ences in the media in which the respective par- tides are suspended, and not to differences in resisting power possessed by the particles them- selves. This points to an important advantage enjoyed by substances like sulphurous, acid or carbolic acid, which appeax less influenced by the nature of the medium, and also shows the necessity of thoroughly mixing disinfectants with liquids or substances to be disinfected. The alkaline or neutral character of virulent sub- stances led Dr. Dougall to select dilute hydro- chloric acid, which has little action upon lead soil-pipes in the cold, as the best disinfectant for excreta. A cardinal principle in disinfection is that it should be carried out at the source, or as near the source of the contagion as possible. Inunc- tion with lard, with caibolised oil (1 to 40), or with glycerine, to clog epithelial, scales, and regular washing and change of clothing, will do much to protect tha purity of the air against oon- tagium proceeding from the skin in such dis- eases as scarlet fever and small-pox. One of ethereal solution lof peroxide of hydrogen to 8 of lard is an excellent application for the skin in typhus. Discharges from the mouth, nose, and bowels, as well as the urine, should be received in vessels containing disinfecting solutions to cover them and give protection to the air ; and then larger quantities, or more concentrated solutions, as the case may be, should be thoroughly incorporated with the discharges before they are removed from the original vessels. Of all agencies for. preventing the spread of communicable disease, cleanliness is one .of the most important. Pacts have been adduced point- ing to the conclusion that filth, when undergoing change of a fermentative or putrefactive nature, is in a condition the most conducive to the extension of infectious disease. Pending the removal of accumulations of dirt, and for the protection of workmen, fermentation may be delayed by the application of crude carbolic acid, chloride of zinc, or bichromate of potash, used in moderate quantity as antiseptics, and the whole accumulation might then be earthed over if it had to remain any time. For real disinfection the large quantity required and the mixing necessary. would be prohibitory. The ultimate fate of contagium is to be de- stroyed by putrefaction, and this appears invari- ably to destroy its specific infective power. In cer- tain cases where real disinfection is impracticable, as in dealing with the accumulation of manure and litter from a number of animals suffering from cattle-plague, the natural processes may be hastened by stacking the material so that it shall 'heat,' or may even be destroyed by sponta- neous combustion. Certainly putrefaction should not be delayed by small additions of disinfec- tants, which cannot accomplish tlxo destruction of all noxious matter present. SPECiAii DisiKFECTANTS. 1. Heat. — Heat, dry or moist, is perhaps the best disinfectant we possess. The experiments of Drs. Henry, Baxter, W. Roberts and others have shown the effects of this agent upon vaccine, malignant pustule, septic microzymr.s, scarlet fever, plague, &c< DISINFECTION. High temperature and length of exposure aie, to a certain extent, mutually oompensatoiy, but it appears that a temperature below 140° T, (60° C.) wiU not disinfect yacaine even with long exposure. Tyndall points out that some genus seem to be in a dormant condition, in which they resist the action of heat unless applied very long or intermittently, so as to start their vitality into growth, when they are easily killed. Ex- perimental &cts show that excessive tempera- tures are as unnecessary as dangerous in practical disinfection. It is extremely improbable that any contagium can withstand a temperature of 220° K, (104-6 C), maintained during two hours. .'Wieii contagium is shielded by thick material, into which heat penetrates slowly, the time necessacv to reach tbe disinfecting temperature may lie long, and hence the necessity for spreading cloth- ing and opening out bedding in special iot-air , chambers, where the heat ought not to be lea than 220° F. (104-5 C), nor more than 250° P. (12M° C). Hot-air chambers are usually bnilt of brick, and are furnished with wooden sup- ports for clothing, which should not come in contact with metal. Dr. James B. Bussell, Medical Officer of Health for Glasgow, has communicated to tho writer the most important fact, that at the In- fectious Diseases Hospital of that city no further disinfection of the linen and clothing of the patients is carried out than is afforded by the boil- ing, washing, &c., requiredin the judgment of the washerwomen to cleanse and drass the clothing ; and yet a continuous careful scrutiny has failed to discover a single case of disease propagated by such clothing. It is probable that soda is used in the Veiling, in some cases at least, and the extreme softness of Glasgow water doubtless helps by its osmotic and dissolving power. 2. Caxbolio Apid. — A solution of this sub- stance of the strength of S per cent., or 1 in 20, is the only one fit for use in disinfection. For steeping fine clothing a solution should be made from crystals. The solution generally useful is that obtained by making up one gallon of crude 80 per cent, acid to sixteen gallons with water. To disinfect a suspected liquid, an equal volume of one of these solutions is needed The results of the experiments of Baxter and others prove that 'no virulent . liquid can be considered disinfected by carbolic acid unless it contain at least 2 per cent, by weight of the pure acid.' A preparation called MacdetiffaWi Powder contains carbolic acid, but is inferior to the pure kinds, though safer and more applicable in many cases to prevent odour. Judging from the li^ht of experiments, carbolic acid vapouT' is quite useless, though clinically Mr. Crookes and Mr. Hope thought it of use in cattle-plague, but the animals and surroundings were drenched wilih liquid acid or solution. Though carbolic valour appears impotent asregards effect upon contagium it will preserve the freshness of a bit of meat suspended in it for months. Very small quan- tities of the liquid acid mixed with organic fluids enables them to remain fresh and resist decay for a long time. So little as one-fifth po' cent, preserves milk. It is obvious then that small quantities of this disinfectant, instead of destroying contagium, may actually preserve itf DISINFECTION. 399 activity, -when otherwise it would have buo cumbed to the aotion of natural agencies. This danger may accompany the limited use of any disinfectant that has a 'pickling '_ or preserva- tive aotion in small quantity. Owing partly to the volatility of carbolic acid, which removes it in time, and partly to the peculiarity of its action, another danger attends its use in any- thing short of full strength and full dosea when applied to kill contagium. The acid may, for a time, deprive the contagium of _ its infective power without permanently abolishing it, and the virulent properties may he regained when- ever the acid has evaporated. This has been proved Bxperimeutally by Dr. Dougall, of Glas- gow, who found that vaccine mixed with carbolic acid (1 in 50) regained its infective power after 10 days' exposure to the air. Carbolic acid coagulates albumen when in iuflciently strong solution; while it restrains putrirfaction, and limits the growth of low forms of animal life. It decomposes potassium per- manganate, and therefore cannot be used in conjunction with this agent or with chlorine. Though it does not destroy sulphuretted hy- drogen, it is a good deodorant in some -cases. When Demonstrator of Anatomy to the Uni- versity of Edinburgh, the writer experimented on a large scale with different substances for removing odour from the hands of the stu- dents, after working in the dissecting-room, and found that a 1 per cent, solution of carbolic acid is superior in efficacy to permanganate, even when strong enough to stain the skin, and is also preferable to chloride of lime. In this connection it ia worthy of remark that the ' septic ferment ' connected with septicsemia, ery- sipelas, &c., appears to be destroyed by rather less carbolic acid than vaccine requires. 3. Sulptur Dioxide. — The aqueous solution of this substance contains sulphurous acid. Bax- ter's experiments showthat it is the most potent volatile disinfectant known; and as it is very soluble, and is little affected by the presence of albumen, it is also powerful in the disinfection of liquids. It destroys sulphuretted hydrogen thus, SO J + 2H2S = 2H30 + Sj, and combines with ammonia. A strong solution of sulphurous acid is sold, but is difficult to use, on account of its suffocating odour. The solution can be made by deoxidizing hot concentrated sulphuric acid with copper-turnings or charcoal. For aerial disinfection the best plan is simply to -burn sulphur in very large quantities. This dis- infectant forms sulphites, and is a reducing or deoxidizing agent, in the first place, for it unites with the oxygen of many compounds to forni sulphuric acid; but it may give up oxygen, and when mixed with much vegetable matter the sulphur may come off as siilfihuretted hydrogen. Sulphur dioxide and chlorine, as well as this substance and permanganate of {jotash, mutually destroy each other, arid therefore should not be used toeether. Sulphur dioxide destroys the activity of dry vaccine on points very rapidly, and even when much diluted stops the amoeboid movements of living cells, kUls vibrios, and acts deleteriously on vegetation. '"Whether chlorine or sulphur dioxide be chosen, it is desirable that the Space to be disinfected should be kept satu- rated with the gas for not less than an hour.' ' A virulent liquid cannot be regarded as cer- tainly and completely disinfected by sulphur dioxide, unless it has been rendered perma- nently and strongly acid. The greater solubility of this agent renders it preferable, txeteris paribus, to chlorine and carbolic acid, for the disinfection of liquid media ' (Baxter). According to Baxter's experiments, a larger percentage of sulphur di- oxide than of carbolic acid is required for the disinfection of the virus of infective inflammation, but a smaller percentage for other contagia. Sul- phur dioxide preserves meat and other substances, when in closed vessels, for very long periods. It bleaches vegetable colours, attacks iron, and is absorbed by cloth and leather — facts to be remembered in practical disinfection. 1 lb. of sulphur, when burned, produces 117 cubic feet of sulphur dioxide gas. 4. Chlorine is most easily obtained from chlo- ride of lime or bleaching powder, by adding hydrochloric or sulphuric acid. Exact propor- tions cannot be stated, as the value of the bleaching powder varies ; but rather more acid than equal parts of bleaching powder and strong hydrochloric acid may be taken. The acid should be diluted before use. Another method is to pour strong hydrochloric acid upon heated binoxide of manganese; this method of disinfec- tion is impracticable compared with burning sul- phur. For deodorizing water-closets, some crystals of potassium chlorate may be thrown into a wide- mouthed bottle containing dilute hydrochloric acid. Euchlorine comes off gradually, and is both more effective and more agreeable than chlorine. The most marked character of chlorine is its strong af&nity for hydrogen, which enables it to break up compounds containing that body, and to set free in a nascent or active state the oxygen combined with hydrogen in water. It is, there- fore, one of the most universally applicable and powerful deodorizers in existence. Direct ex- periment shows that ' there is no security for the effectual fulfilment of disinfection short of the presence of free chlorine in the virulent liquid, after all chemical action has had time to sub- side.' Chlorine ia soluble in water to the extent of 2| volumes in one, and this solution may be used for disinfection. When merely used as a deodorizer, enough euchlorine may be expelled from moist chloride of lime by the carbonic acid of the air for most purposes. 5. Permanganate of Potassium. — This sub- stance is non-poisonous, and is a good deodo- rant, especially for the emanations from organic bodies. It is, moreover, free from odour, and its' aqueous solution shows, by loss of colour, when it is exhausted. It is- a very suitable deodorant for the sick-room, as, when dissolved in water and a large surface of the solution ex- posed to the air, it will absorb gases to some extent. Contagium being non-gaseous, ia not aifected, unless in contact -with the solution. Permanganate of potassium is a true disinfec- tant, oxidizing and deetroyilig contagia as well as putrid -matters ; but' the Quantity required and the price render its use almost impossible, for enough permanganate has to be used to de- stroy the medium or vehicle bearing -contagium as well as the contagium itself. Condy's fluid is 100 DISINFECTION. a solution of this substance in water. 'When permanganate of potash is used ia disinfect a virulent liquid containing much organic matter, or any compounds capable of uniting with the permanganate, there is po security for the effec- tual fulfilment of disinfection, short of the pre- sence of undecomposed permanganate in the liquid, after all chemical action has had time to subside ' ( Baxter). "When the virulent liquid or matters are small in quantity, permaganate solution forms » capital receptacle, and may stand by the bedside as a deodorant till re- quired as a disinfectant. The safe rule in employing permanganate as a disinfectant as to add it and mix till the colour is retained. Permanganate has no effect ip restraining the appearance of bacteria, or preventing the onset of putrefa.ction. 6. Acids. — The mineral acids and glacial acetic acid have all disinfecting power when used in sufficient quantity; buti except sul- phurous acid, there are serious dif^culties in the way of their use, and' we have better disinfect- ants. Hydrochloric is inferior to chlorine as a gaseous agent; but the solution is extremely cheap, and is .useful for disengaging chlorine, as well as for employment as adisinfeotant. Chromic acid, which has remarkable power in preventing putrefaction and killing microzymes, is too dear to be used outside the laboratory. 7. Ifitroua Acid. — ^Nitrous acid can be easily disengaged as a gas by putting bits of copper into nitric acid, or pouring nitric acid upon saw- dust or starch. It is the best deodorant for the deadhouse, and, without doubt, it is a vigorous disinfectant, but is too dangerous for ordinary use, as it may easily be breathed in quantity sufficient to cause fatal bronchitis. 8. Chloride of Ijlme. — Bleaching -powder gives off chlorine easily, and this probably ex- plains its disinfecting power. It is very cheap and manageable, and hence of much importance. In regard to the agents hitherto considered, we have more or less of the sure light of direct experiment upon contagium; but the claims of the following and a legion of other substances asserted to be ' powerful disinfectants, of which it is impossible to speak too highly,' rest entirely upon chemical theories, or the opinions of phy- sicians, or upon their power of coagulating albu- men, or of delaying or preventing putrefaction and fermentation, or of deodorising. It will be scarcely necessary to do more than enumerate the best, as follows : — 9. Metallic Salts, including — a. Biohromate of Potash, b. Sulphate of Copper, c. Chloride of Zinc (Burnett's Fluid) which can be made very cheaply by pouring hydrochloric acid upon calamine, the native carbonate, or upon zinc. It seems to be the most useful of the metallio salts, d. Chloride of Alvminium, e. Ferric Chloride, which, if strong, liberates offensive fumes from animal matters, but is a fair anti- septic and preservative. /. Ferrous Sulphate, g. The Waste Chlorides, from the manufacture of chlorine, contain MnClj, FojCl,, and free HCl, which cost next to nothing, and might be used for larger masses of filth or drains, 10. 0»one.— This body, got by half immers- ing a stick of phosphorus in tepid water, or mixing gradually 3 parts strong sulphuric acid and 2 parts permanganate of potassium, oxidises organic matter, and so destroys odours. Tere- bene and cupralnm, a preparation containing terebene, are good deodorants, and give rise to ozone. 11. Charcoal. — Charcoal condenses gases within its pores where combustible gases are de- stroyed by the condensed oxygen. Contagium, unless in water, does not enter the pores, for, being particulate, it is not absorbed from the air as gases are. Pkactical Disinfection. — ^In conclusion a few remarks may be offered as to the modes of carrying out disinfection under circumstances in which it is commonly required. 1. Clothing and bedding. — In dealingwith the ragged and worthless articles of the poor, local authorities wUl generally find it most satisfac- tory to both parties to burn them and replace with new. By such discreet generosity danger is averted, and good-will created, which helps in getting early information and carrying out measures, and so, by shortening epidemics, saves expense. If not burned, clothing may be baked (see Heat), or well boiled with soda. Before coming to the washhouse they may steep in 5 per cent, carbolic solution^ or chloride of zinc (1 to 240), or chloride of lime (2 oz. to the gallon), 2. Booms. — The foundation for disinfect- ing rooms is thorough cleansing with soft soap and hot water, which may contain 5 per cent, carbolic acid, but the carbolie solution is not so easily handled. The walls and coiling should be brushed, and wall-paper removed. Purniture, if iron, is to be washed with carbolic solution, and removed from the room. Textile fabrics should be baked orboiled,or spread out in the room for fumigation, but this is not so effective, and colours are bleached. The chimney, doors, and windows are to be closed, and crevices covered with paper pasted on. Then one or more tubs of water are to be placed in the room, and an earthenware saucer containing sulphur placed over each, supported by a pair of tongs laid across to prevent danger from £ie. The sulphur can be lighted by pouring a little alcohol upon it, or by means of a live coal. The usual rule is to use 1 lb. of sulphur, for each 1,000 cubic feet of space, but this only gives 1-17 percent. SOj to the air, and 3 lbs. is a more satisfactory quantity. The door is to be shut until next day, when the windows and doors are all to be opened, and kept open for twenty-four hours. In whitewashed rooms the walls should be scraped, and then washed with hot lime in addition to the fumigation. 3- Drains,WateT-closets,&c.— Froperdrains remove sewage so swiftly and completely, that little or no sewage-gas is formed if ventilation is given. For bad drains carbolic acid, chloride of zinc, or waste chlorides from the manu- facture of chlorine are fair palliatives. The excreta from cases of infectious diseases require a very large quantity of disinfectant, which should be applied in a concentrated form before they are thrown into the water-closet or hojise pipes. When a reliable amount of disinfectant is in these cases sent down the pipes, it is apt to corrode them unless it has been allowed to DISINFECTION. expend, its energy on the excreta alone in tlie 6i'st place. If small quantities of disinfectants are poured doTm water-closets, it is better to mix them -with the after-flush water which fills traps and basins, so that the little energy available may be devoted to the destruction of any slime adhering, or portions of organic matter retained. Permanganate of potash is the most pleasant agent for this purpose, though expensive. Chloride of zinc, from its cheapness and preservative power, is worthy of mention. When there are no water-closets, the excreta in cases of cholera and typhoid fever should be received in a vessel containing half a pint or more of a 1 in 20 solu- tion of commercial hydrochloric or sulphuric acid, and then put along with some chloride of lime into a covered stoneware vessel in the back yard. After a few hours the contents of this vessel may be thrown into the cesspool or upon the midden. 4. Dead bodies, if putrid or bearing conta- gium, should be wrapped in sheets wet with 1 in 20 carbolic solution, or 1 in 40 chloride of lime ; or, if cofiined, sawdust saturated with one of these solutions should be packed around them. It is necessary clearly to keep in view the object desired when selecting disinfectants, deo- dorants, or antiseptics ; whether it be destruc- tion of contagium, merely 'pickling' and pre- serving, arresting putrefaction and fermentation, or deodorisation. From all that has been said it is evident that the different 'disinfecting' nostrums, applied as their inventors direct, can have little efl'ect upon contagium, but may have more or less power in the other directions indi- cated. James A. Kcssbll. DISLOCATIOIT OI' OEGABTS {dia-, apart, and locus, a place). See Okoahs, Dislocation of. DISPLACEMEETT OF OKGAW3. See Organs, Displacement of. DISSECTION - "WOUNDS. See Post- mortem Wounds. DISTOMA (51s, double, and arSfui, a mouth).— Stnon. : Fluke; Fasciola; Fr. dis- tome ; Ger. Lebervmrm. — A genus of trematode parasites, vulgarly called flukes. The term was founded by Retzius in 1786 ; but the title Fas- ciola, previously employed by Linnaeus, is tbie more correct, especially when applied to the common liver-fluke, which is an occasional in- habitant of the human body. Nearly twenty in- stances of the occurrence of this pa,rasite {fiistoma hepaticmn of some writers) in man have been placed on record. Besides infesting the liver- ducts and gall-bladder, it has been found under the skin behind the ear (Fox), beneath the scalp (Harris), and in the sole of the foot (Giesker). Several other species oif illuke are known to infest mankind, but with the exception of the Egyptian hsematozoon {Bilharsia Jusmatobia) none of therri are of frequent occurrence. Thus the lancet-shaped fluke ', (BistowA lanceolai-um) has thrice occurred, leading to a fatal result in a single instance, whilst tlie minute Distoma hy- tero'phyies has only once been recorded. The large human fluke, sometimes known as Busk's fluke (Biitoma eramm) had also, until lately, only once been noticed; but, through Dr. George Johnson, the writer has become acquainted with 26 DIURETICS. 401 two more instances of infection from this para- site, and there is some groimd for believing thet the cases of fluke described by Dr. Leidy of Philadelphia refer to the same parasite. More recently also {Lancet, 1875) Dr. McDonnell has recorded the occurrence of an un- doubtedly new species from a Chi- nese, for which the writer has pro- ■ posed the title of Distoma sinense. Large numbers infested the ducts of the liver. Professor Leuckart subsequently proposed the term JOisioma apathulatum. Professor McGonnell has also discovered an- other fluke in man (D. conjunctum, Cobbold) previously only known to infest the fox and dog. Taken as a whole the human flukes referable to the genus Distoma have very aiametera. little chnical importance ; but, since After MoCon- there were striking symptoms in "^ll- connection with the above-mentioned cases of Distoma ct^ssuot (^aflfecting an English missionary and his wife during their residence in China) it may be as well to mention that these large para- sites, individually varying from one to three inches in length, appear to be capable of inducing severe diarrhoea and colic. Their organisation is totally distinct from that of the common fluke. They probably never gain access either to the liver or its ducts. (Proceed. Liim. Soc, Feb. 1875.) The administration of santonine, male fern, and other anthelmintres has been unat- tended with positive results ; those specimens that were expelled seeming to have been, as it were, starved out by the patients having been put upon a milk diet, recommended by Dr. Johnson. The missionary and his wife having returned to China were again attacked by Distoma crassum. In the spring of 1878, they again consulted the writer in London, not only on their own account, but also on behalf of one of their children, a little girl, who had also contracted the fluke-disorder in China. Flukes have twice or thrice been de- tected in the eye, but they appear to have beefl sexually immature worms, referable probably, as Leuckart has suggested, to the Distoma lanceola- tum.^ The flukes described by Treutler and Delle Chiaje, if genuine, have no clinical importance. See BttHAEziA. T. S. Cobbold. DltJKESIS (8ia, through, and ovpea, I pass water). — A free excretion of urine, whether natural or artificially induced. DIUKBTICS (Sio, through, and oipeaj Ipass water). Definition. — Remedies which increase the secretion of urine. Enumeration. — The following comprise the most important diuretics: — ^Water; salts of Potash, Soda, and Lithia; Alcohol, Nitrous Ether Turpentine, Juniper, Copaiba, Cantharides' Digitalis, Squill, Tobacco, and Scoparium The action of diuretics is often aided by brisk purga- tion, depletion, counter-irritation over the loins, and sometimes by the use of mercury. Action.— The secretion of urine appears to consist partly of mechanical filtration of fluid 102 DIUEETICS. through the glomeruli of the kidney, and partly of Beoretion by the cells of the urinary tubules. The filtration in the glomeruli is increased by anything which raises the blood-pressure throughout the system generally; or in the renal arteries locally. The systemic blood- pressure may be raised by cold to the surface; digitalis, squill, and tobacco. Digitalis, and possibly other drugs have also a local action on the renal arteries, which are more readily affected by some drugs than other arteries in the body. The exacc mode of action of the other diuretics is not determined, but common salt, nitrate of potash, urates, and urea increase the flow of urine, even although the pressure in the vessels of the kidnfey is very low. It is there- fore probable that they stimulate secretion by acting on the nerves or cells in the kidney itself. Uses. — Diuretics are employed to increase the flow of urine, aiid thus remove water or ,ex- crementitious products like urea from the body. They are used in cases of general dropsy, or of accumulation of fluid in the peritoneum or pleura. In febrile conditions they are given to aid in the elimination of waste matter. They are also employed in order to render the urine more watery, and thus prevent the deposition of solids from it, and the formation of calculi in the kid- ney or bladder, or to redissolve such concretions when they are already formed. Digitalis and squill are most useful in dropsy dependent on heart-disease ; the other remedies are more effec- tive in dropsy dependent on disease of the kid- neys or liver. The action of digitalis and squill is greatly assisted by the addition of a little blue pill, and when the kidneys are much congested or pressed upon from without by accumulation of fliiid in the abdominal cavity, diuretics some- times fail to act until the congestion has been relieved by depletion from the loins or the use of a brisk purgative, and the pressure removed by paracentesis. T. Laudeb Bednton. DIZZIWESS. &cV:^TiH0. DOCHMITTS (SJxiuos, twisted). — A genus of nematoid' worms established by Dujardin. See SCLBEOSTOMA. DOTHIWEITTEBITIS (SofliJii', a pustule, and hrtpoii, the intestine). — A synonym for a form <.£ enteritis, accompanied by an enlargement of the follicles, which causes them to resemble pustules. See Intestihe, Diseases of. DOttoHB (Fr.).^DEFiNiTiON. — A jet of water propelled against some part of the body through a doccia or pipe. The size of the jet o| water, the degree of its impetus, and its tempera- ture, can all be regulated. A douche differs from simple affusion in its application, being more local, and the force with which it is applied being greater. Application and Action. — Douches of cold and of hot water, of vapour, and occasionally of gas are employed ; but those by far the most •'i|ommouly used, except where there are hot natural waters, are of cold water. The immediate effect produced by a cold douche on those who are unaccustomed to it is a feeling of shock, spasmodic shortness of breathing, palpitation of the heart, and some- DOUCHE. times pain in the back of the head. Locally the first effect of a douche is to deaden- the sensi- bility of the part to which it is applied; but if the douche be powerful enough, reaction of the part comes on in about forty seconds. This continues for a time ; but if the douche be kept up for three or four minutes, the pulse falls seven or eight beats, the deadening of sensibility re- turns, and the temperature of the part is greatly lowered ; when the douche is withdrawn re- action again takes place. This alternate seda- tivk and stimulating effect, producing emptiness and turgescence of the vessels, quickens the action of the capillaries of the part, and thus favours the transmutation of tissue. The meehar nical effect of the force with which the douche is applied must not be overlooked. If great, it produces the highest amount of stimulation, which may almost amount to inflammation. Different portions of the body have diiferent degrees of tolerance of the douche. Thustho extremities and the head bear it better than the chest, and the chest somewhat better than the abdomen ; and the posterior aspect of the hody bears it much better than the anterior. Patients soon get accustomed to the cold. Warm douches produce' less shock, and are more easily borne, but they are, comparatively speaking, little em- ployed in private houses. An alternation of hot and cold douches, known somehow by the name of Scotch, is a valuable remedy; in it the hot water rapidly restores the irritability of the part deadened by the cold water, and there is a maxi- mum of action and reaction of the part obtained. Under particular circumstances it may be expe- dient to use a jet of steam, but this, of course, must be used with, caution ; and a jet of carbonic acid is sometimes propelled against the eye or ears, or the neck of the uterus. What are called ascending douches are used for the rectum or the vagina. Douches for the eye and the ear have beenusedof late years. In a certain, sense what the English call pumping is a variety of the douche, and the shower-bath is in reality merely a multiplication of fine douches. The action of douches is more or less general according to the portion of the body to which they are applied. Thus the application of a douche to the head has the most general action, and that to the spine the next so. In either case it is impossible to limit it very strictly, and there is a certain amount of affusion besides the direct douche. A douche, again, applied to one of the extremities may easily be localised; and o douche maybe applied only to one part or to several parts of the body in succession. Douches merely require a pipe with nobles of various sizes in connection with a cistern at a certain elevation, or with a pumping machine, and can easily be improvised. Showeu-haths can be procured with equal facility. A vapour douche can be got byattaching a pipe to a vessel of boiling water. In the case of the fine douches used for the eye, the water is propelled with suf- ficient force by the action of a caoutchouc bag worked by the hand. Carbbnip acid is practically little used, and only where there is an abundant natural supply of the gas. Perhaps 60" may be considered the average temperature of a cold douche, and irom fonl DOUCHE, minntes to a quarter of an hour its average dura- tion. The course of douching iirill probably ex- tend at least over a fortnight. As to the actual temperature of the water, the sensation it pro- duces in the patient depends most on his con- dition. Thus water of 46° may feel ice-cold to one who has just quitted a hot bath. In like manner a douche of slightly-heated water may appear quite warm when applied to a part cooled by a cold douche. The temperature of a douche jhould rary according to the condition of the patient. UsBS.— As a general rule we may say that douches are only applicable in cases of chronic diseaae; that cold douches are most useful in constitutional diseases; and that warm douches, and the alternation of hot and cold, are most suitable in local affections. The cold douche, when it is employed gradually and with judgment, is found serviceabk in chlorotic and hysterical conditions, in hysterical paralysis, and in OTer-sensibility of the skin, with tendency to catch cold ; and of late years it has formed a part of the special treatment of phthisis in elevated places. As cold affusion on the head is very serviceable in infantile con- vulsions, so the application of a douche of cold water to the head is a calmative and hypnotic in maniacal cases. It is, perhaps, not so much used in this way as formerly;, as it has, like the shower-bath, come to be considered a sort of pun- ishment to troublesome lunatics. Still it is a valuable agent. Hydropathic practitioners have found douches useful revulsives in congestion of the liver and of the uterus. Locally douches have been used, but with moderate benefit only, in some cases of skin- affections and fflf chronic ulcers. Their prin- cipal local application, however, is in cases of old sprains, in chronic rheumatism or gouty thickenings of joints, in lumbago, in some neu- ralgias, and in paralysis when it is not too recent. The Scotch is far the most effective for_ these purposes, and there seems to be some evidence of its having been efficacious in threatened tabes doTsalis — certainly more efficacious than any other remedy. Doiiching might be used more extensively in private houses; still, as assistance is always required by the patient, public baths have advantages for their application. JoHS Maophekson. DBACUNCTJIiTTS [drcumnotU'US, a little dragon). — A synonym of the guinearworm. Under this title the parasite was described by Lister (PAiJ. Train., 1690), and afterwards by Kaempfer (1694). Following the latter autho- rity the vmter has elsewhere recognised the term as of generic value, but the majority of helminthologists, after Gmelin, prefer to place Pig. 17«— DrocuneuZuj Medinensis^ Ecduced to \. the worm under the genus Filaria {F. medi- neniW). The Dracnnculus ' was known before the time of Lister, having been described in a remarkable work by Velscius (1674) and by Agatharchidas as quoted by Plutarch. There is, DROPST. 4oa indeed, every reason to believe that the so-oallod fiery serpents of Moses answer to the dracnneuli of Plutarch. The matter is frilly and learnedly disoussea in Kiichenmeister's treatise {Parcmten, S. 305 ; also in the English edition, p, 390 et seq.). See Guineawohm. T. S. CoBBOtD. DKAIITAGE. See Public Health, DRASTICS (ipio), I act). Definition. — Violent purgatives, Enhmeeation. — The drastics most frequently employed are: — Hellebore, Podophyllin, Gam- boge, Elaterium, Scammony, Jalap, and Croton oil. For action and uses of drastics, see Puboa- TiVBS. T. Laudeb Bkunton. DBIBtJBG, in "Westphalia. Strong Chaly- beate Waters. See Mineral Watebs. DBOITWIOH, in ■Worcestershire. Com- mon Salt Waters. See Mineral Watbes. DBOPSY (SSpmfi; from iSap, water, and Si)., aspect, appearance). — Synon.: Pr. Hydro- Ger. Wasseraiicht. Definition. — Accumulation of serous fluid in the subcutaneous cellular tissue, or in a serous cavity. Dropsy is known by various other names, according to the portion of the body affected. When confined to the subcutaneous cellular tissue it is termed cedema or anasarca ; to the peritoneal cavity, ascites. The term is often limited to these two forms of the disease ; and exudations similai: to that of ascites in other cavities are teriried M/dropericardium, hydroce- phahis, hydrocele, hydrops oaili, hydrops articuli, and hydrothorax or pleural effusion, according as they are contained in the pericardium, arach- noid, tunica vaginalis, eye, joint, and pleura re- spectively. Pathologt.— The accumulation of fluid in the tissues, or in a serous cavity, depends upon more fluid exuding from the blood-vessels than can be taken up by the absorbents. So long as no obstruction to absorption occuis, it rarely happens that more fluid can exude from thie blood- vessels than the absorbents can again take up. Absorption is partly cairried on by the veins, and partly by the lymphatics ; principally, however, by the veins. When venous obstruction takes place, fluid is apt to accumulate in that part of the body from which the blood ought to return by the obstructed vessel. But it does not I always' So accumulate ; for it may happen that the lymphatics are able to absorb all the fluid which exudes from the capillaries, and to return it into the general circulation. Thus it has been found by Eanvier that ligature of the vena cava in a dog does not usually produce cedema of the lower extremities, but if one sciatic nerve be divided in such an animal, the corresponding leg at once liecomes (edema- tous. The reason of this is that so long as the nerve is intact, the lymphatics can absoyb" all the fluid which exudes from the capillaries, but when the nerve is divided the arteries dilate, more fluid is poured out than the lym- phatics can absorb, it accumulates in the tissneBj and oedema ensues. This cedema is not due to 101 paralysis of the limb, but to paralysis of the vessels. Por if the sympathetio fibres through ■which the vaso-motor nerves pass to the sciatic nerve are divided before they join the motor fibres of that nerve in the sacral plexus the power of movement remains unimpaired, but oedema occurs just as if the whole nerve had been divided. If, on the other hand, the motor strands of the sacral plexus are cut before they are joined by the sympathetic fibres, the limb is as completely paralysed as if the sciatic nerve had been cut, but no oedema takes place. Any obstruction to the venous flow will operate in the same way as ligature of a vein, though to a less extent, the effect varying accord- ing to the amount of obstruction. Thus regurgi- tation of blood through the tricuspid valve tends to produce general anasarca, and obstruction to the portal vein by cirrhosis of the liver tends to cause accumulation of fluid in the abdominal cavity. It has been mentioned how great an influence dilatation of the arteries from vaso-motor paraly- sis has upon the production of oedema in cases where the veins are obstructed. Arterial dilata- tion may also produce a local oedema, even when no such obstruction is present, as, for instance, in the tissues around an inflamed part. It has been shown, however, by Winniwarter, that the walls of vessels in an inflamed part are more permeable, and allow fluids to pass through them more easily than healthy vessels will do. It is probably in eonsequence of this that we find that a slight stimulus, such as scratching the skin, which ordinarily produces in a healthy person only slight dilatation of the capillaries, and consequently redness of the part scratched, will produce an effusion from the vessels, and local swelling of the part at the point scratched in persons suffering from urticaria. The same thmg takes place when the skin is scratched in the neighbourhood of a part stung by a wasp. But this alteration in the vessels is not the only cause of the cedenui, which may occur without any obstruction to the circulation. An alteration in the composition of the blood ap- pears to allow it to permeate more easily into the tissues, and to produce oedema, even when there is no obstruction of the veins. In cases of anaemia we find oedema occurring at the ankles, although there is no obstruction to the venous ciroulatiou other than that caused by the weight of the coliunn of blood itself. In these cases, however, we have dilatation of the vessels, as is shown by the form of the sphyg- mographic tracing, and an altered composition of the blood is evidenced by the anaemic look of the patient- The dropsy of scurvy is probably also due to- blood-vascular disorder. In albu- minuria the altered composition of the blood appears to be the chief factor in the production of oedema, as the pulse in such cases may be haid, evidencing arterial contraction, and not relaxation. MnoiMOY. — Gfeneral dropsy affecting the subcutaneous tissuBr the peritoneal cavity, and the internal serous cavities and organs generally, is usually the result of albuminuria, and most frequently of that form which depends on fatty degeneration of the kidney. In cirrhotic disease DEOPSY. of the kidney the loss of albumen in the urino is much less, and the alteration in the com- position of the blood consequently is not so great as in the first-mentioned form. The arte- rial tension also is greater than usual, instead of being less. In the amyloid form the oedema is generally^moderate. The next most common cause of dropsy is tricuspid regurgitation, obstructing the venous circulation throughout the body. This regurgi- tatiou generally depends on dilatation of the right ventricle consequent upon obstruction to the flow of blood through the lungs, either from chronic bronchitis and emphysema, or mitral obstruction and regurgitation. Dropsy from cardiac disease generally appears first in the feet if the patient has been for some time in an upright position, while dropsy from albuminuria is often first remarked by a puffiness of the eye- lids. In the former it appears where the greatest obstruction to re-absorption takes place, and ia the latter case in those parts where looseness of the cellular tissue most readily allows of exuda- tion. Local dropsies have, as a rule, local causes, Even the swelling of the feet in anaemic young women, although dependent on a general cause, viz., dilatation of the vessels, and altered com- position of the blood, is determined locally by the greater obstruction to the venous circulation which the. pressure of the long column of blood in the veins between the feet and the heart presents. In general dropsy also, those parts which are most dependent are apt to become most swollen. It is not, however, always so, as in certain cases the dependent parts have been noticed to be less dropsical than the others. This curious phenomenon seems to be due to some vaso-motor nervous influence ou the vessels of the dependent part. The local oedema of a brawny character, often noticed around in- flamed parts, is partially due to swelling of the tissues themselves, and partially to effusion of fluid between them. This ef^ion, as has already been mentioned, appears to be caused both by the dilatation of the vessels observed in inflamed parts, and by the greater readiness with which fluids pass through them. Dropsy in Serous Cavities. — The serous cavities of the body, the arachnoid, pleura, peri- cardium, peritonaeum, &c., are now known to be large lymph-sacs, in communication with the general lymphatic system of the body. The fluid which exudes into them from the blood- vessels is, in the peritonaeum and pleura, removed, at least in part, by a pumping action in the movements of respiration. The central tendon bf the diaphragm contains spaces, the walls of which are alternately drawn apart and pushed together during its ascent and descent. Their separation draws up lymph from the abdominal cavity, and their compression forces it onwards through the lymphatic vessels. The same thing occurs in the costal pleura, during the respiratory expansion and contraction of the chest. The accumulation of fluid in serous cavities may be due, like its accumiHatioD in the cellular tissues, either \a diminished absorption or increased exudatiop> The diminished absorption occurs hero in conse- quence of pressure upon veins, and possibly ttlsp DROPSY. from interference with the pumping action just described. Accumulation of fluid in the ven- tricles of the brain, or in a sub-arachnoid cavity, is chiefly duo to compression of the veins of Galen. In the peritonaeum it may be duo to obstruc- tion of the portal vein by cirrhosis of the liver or by the pressure of tumours, and it may occur to a greater or less extent in all cavities of the body — from general obstruction of the venous circulation, by disease of the heart or lungs, in the same way as anasarca. It may also occur in these cavities from alteration in the blood, as in Bright's disease. Active dropsy may occur in a serous cavity from inflammation, and here the exudation of fluid is much more rapid than in passive dropsy, the vessels of the in- flamed part being dilated and more pervious than usual. Tbbatment. — The first thing to be considered in the treatment of dropsy is the removal of its cause, if this be at all possible. Where it is due to obstruction of a vein we must hinder, as much as possible, the accumulation of fluid in the vein, by preventing the part from remaining in a dependent position, while at the same time we try to aid the absorption of fluid by the lymphatics by gentle upward friction. Where it is due to obstruction of the circulation in the lungs, we must diminish, as far as possible, all obstructions to the pulmonary circulation by inhalations, emetics, and expectorants, pushed if necessary so far as to cause nausea or even vomiting. Where, the obstruction is due to dilatation or valvular disease of the heart, we must aid the organ to contract more powerfully by the use of cardiac stimulants, such as alcohol and digitalis. Digi- talis probably has a threefold action in cardiac dropsy, by strengthening the heart, by contract- ing the vessels, and by stimulating the kidneys. It strengthens at the same time that it slows the cardiac pulsations, and by making the heart con- tract more powerfully it keeps up the onward current of the blood more efficiently, and at the same time lessens the dilatation which tends to render the valves incompetent. Besides its efiect on the heart, digitalis has also an action on the vessels, causing the arterioles to contract, and probably reducing the dropsy in this way. For the contraction of the arterioles produced by digitalis is exactly the converse of the condition which occurs after division of the vaso-motor nerves, and which, as we have seen, produces dropsy whenever any obstruction of the circula- tion exists. It is not known at present whether digitalis also causes increased absorption, but it seems highly probable that it does so, because we know that it stimulates the vaso-motor centre, and stimulation of this part of the nervous system has been shown by Goltz to increase greatly the rapidity of absorption from the lymph-sac of the frog. In addition to this action on the heart and vessels generally, digitalis possesses a specific action upon the vessels of the kidney. It is a powerful diuretic; and by thus lessoning the amount of water in the blood it will tend to in- crease the absorption of serous fluid either from the_ cellular tissue or serous cavities. When digitalis alone does not succeed, the addition of aquill and of a small quantity of blue pill fre- quently increases its efficacy. Digitalis succeeds DEOWNING, DEATH BY. 40fi best in dropsy caused by valvular disease or dilatation of the heart. It is not so useful in dropsy arising from renal disease, and here other diuretics are preferable. One of the best is spirits of juniper, given either as a mixture or in the form of Hollands gin. Spirits of nitrous ether, nitre, bitartrate of potash, and broom are useful in all forms of dropsy. Copaiba occasionally succeeds where other diuretics fail. It seems to be most successful in dropsy due to cirrhosis of the liver. Hydragogue cathartics, such as com- pound jalap powder, elaterium, &c., which cause copious watery secretion from the intestines, sup- plement the action of diuretics, and by removing water from the body, as well as altering its nutrition, relieve or remove dropsy. In some cases of Bright's disease considerable relief has been obtained by the profuse sweating induced by vapour baths, hot-air baths, jaborandi, or pilocarpin. When the dropsy does not yield to other remedies, the fluid must be removed by paracentesis in the case of serous cavities, and by very small superficial incisions or punctures, or by the insertion of very fine troehars with drain age-tubes attached, in the ca^e of the limbs, T. LiUDEH Beunton. DBOWWIlfa-, Death by.— Drowning is employed, in an extended sense, to signify death from submersion in a liquid medium, and in a more restricted sense to signify death in consb- quence of obstruction of respiration so caused. Now, though death must necessarily ensue from asphyxia, when the air-passages are submerged, apart from any other complication, asphyxia is not always th'e mode of death in those who were alive at the moment of submersion. For death may result from mechanical injuries, concussion, shock, syncope, or apoplexy in the very act, or at the moment, of falling into the water. Devergie estimates that 12'5 per cent, of deaths occur from one or other of these causes. In the remain- ing 87"5 per cent., the phenomena of asphyxia pure and simple are present only in 23 per cent., while in 62'5 per cent, these are more or less modified by the causes above-mentioned, to which must be added the benumbing influence of cold. Wlien death is not sudden from shock, &c., the ultimate result is the same in the swimmer or non-swimmer, if there be no escape or rescue. All efibrts to keep above water fail, vain clutch- ings are made at whatever comes within reach, water is drawn into the lungs and more or less swallowed, all struggles flnally cease, and the body sinks. The indications of such instinctive efforts form the most important evidence of submersion during life. Drowning is not necessarily to be inferred in the case of a dead body removed from the water ; for the body may have been thrown in after death from other causes — asphyxia among the rest. The Evidence op Death peom Dkowninq is cumulative, for we can scarcely say that there is any one indication invariably present which can be looked upon as due to drowning and nothing else. But one or other, or more, of the following appearances are generally found. External. — The face is either pale, or more or less livid, or frequently bloated if the body hfis 406 DROWNING, DEATH BY. lain some hours in the water. Foam at the mouth and nostrils is very common; and the tongue is swollen and congested, closely applied to the teeth, or even clenched between them. The skin is pale, or marked here and there by livid dis- oolorations, and the muscles of the hair-bulbs are rigidly contracted, causing the appearance of goose-skin, or cutis anserima. The penis is re- markably retracted, so that it appears quite small in proportion to the size of the individual. Indications of struggling are frequently seen in excoriations of the hands, mud and sand under the nails, or even weeds, straws, or other small objects, tightly clenched in the hands. Internal, — The trachea, bronchi, and smaller air-tubes are congested and filled with a mucous froth, more or less tinged with blood. The lungs themselves are congested, cedematous, and pit on pressure. Pressure on them causes froth to exude into the smaller bronchial tubes, and on section a sanguinolent froth and water escape. Indications may be seen of sand, mud, or small weeds drawn deep into the air-passages along with the water in which submersion took place. The stomach contains water. If this has any special character by which it can be identified with that in which submersion occurred, and not likely to have been drunk to quench thirst, it ex- cludes the theory of its having been swallowed before submersion ; and is a strong presumption, if it cannot be said to be a certainty, that it was swallowed during the death-agony, and did not find its way into the stomach after death. The same may be said of water in the lungs. The right side of the heart and venous sys- tem in general frequently present th'e appearances characteristic of asphyxia; and the brain is often congested. Without relying on any one sign as conclusive, we may say that a body which exhibits goose* skin, retraction of the penis, excoriations, &c., of the hands, froth at the mouth, water in the lungs and stomach, and congestion of the right heart and vent)us system, certainly died from drowning. In the presence of some and in the absence of other indications, a careful weighing of all the facts is necessary ; but in most cases a satisfactory conclusion can be arrived at. Complete submersion is usually sufficient to cause death vrithin two minutes ; but cases have been recorded of resuscitation after a much longer period. Many of these can be attributed to the exaggerated estimation of time by anxious on-lookers ; but there are other well-authenti- cated instances, which may be explained by the supervention of syncope and temporary cessation of the respiratory process. That which renders resuscitation after submersion less likely than after a corresponding period of mere suffocation is the entry of water into the lungs by aspiration. Tkbatment. — The treatment of the drowned consists in the persistent use of artificial respira- tion {see Aetifioial Eespieation, and Kesus- citation) so long as any signs of life remain, together with the application of means to coun- teract the great abstraction of body-heat which occurs even when the aerial temperature is com- paratively high. Before commencing the move- ments of artificial respiration, the mouth and nostrils should bo freed from water and froth. DUMBNESS, by holding the head somewhat low, face down- wards, for a few seconds. Artificial respiration should then be immediately proceeded with; and at the same time the wet clothes should be removed and the body wrapped up in warm clothes obtained from bystanders, pending the arrival of warm blankets, hot bottles or bricks &c., from the nearest house. Assiduous friction of the extremities should also be kept up. These directions— artificial respiration excepted— natu- rally presuppose assistance. If this be not at hand, the operator must rely mainly on artificial respiration. In the performance of artificial respiration by Sylvester's method, especial care must be taken against pressing on the stomach, for as it so frequently contains water, this may be pressed up the oesophagus, and drawn into the lungs by the next inspiratory movement. When spontaneous respiratory movementa commence, attention should be directed to main- tain life, by the application of warmth exter- nally, assiduous friction of the limbs upwaide, and the administration of a teaspoonful of brandy and water, wine, or coffee. Lung-complications should be watched for and counteracted. D. FiBBIBB. DKOWSINESS. — Inclination to sleep. See Sleep, Disorders of. DEY. — ^A term applied to certain morbid conditions, to express the entire or comparative absence of fluid exudation or secretion, which is often present in such conditions ; for example, Dry Gangrene, Dry Cavity, Dry Catarrh, and Dry Pleiirisy. Theword is also associated with certain ausculatoiy signs, which convey the impression of want of moisture ; for example, Dry Ehonchus and Dry Crackle. See Physicai Examination. DircHBiirirE's pakalysis. Sm Pseudo-Hypebtbophio Paealysis. DTJCTtrS AETEEIOSUS, Patency of.- See Heabt, Malformations of. DXTMBWESS. — Definition. — The condition of an individual incapable of articulating sounds. Dumbness may arise from a variety of canses, and its prognosis and treatment vary accordingly, 1. Dumbness due to Deafaess. — The most frequent cause of so-called dumbness is congenital or early acquired complete deafness, or defectiye power of hearing, so that the patient is unable to acquire in an ordinary way the knowledge of ar- ticulate sounds. It is important to bear in mind that complete deafness is not essential to this peculiarity. Dumbness is frequently met with in children and others where the only cause is defec- tive power of hearing. ' Treatment. — Whether the outcome of com- plete or partial deafness, the treatment must be based on the belief that the articulating power is latent, and may be developed by imitating the process of speaking in others, and by » metho(^cal training in lip language. It is most important that sign language should not bo cultivated at the same time, and that if a lan- guage of signs, whether by the hand or gesture, have been previously taught, it should be tho- roughly and at once discarded. With patients DUMBNESS, who have full intellechial power, and who are trained as indicated above, it will be found that for them dumbness is a misnomer, articulate sounds, although with a defective modulation, being readily acquired. Individuals coming under this category are erroneously called deaf-mutes. 2a Dumbness from Central Lesion of the hypoglossal nerves— This may arise from cere- bral hiemorrhage, tumours, or embolism, and the prognosis is most unfavourable. It is usually associated with other paralytic conditions, but is of all the most persistent. 3., Dumbness from peripheral lesion of the hypoglossal nerve. — This is much less frequent as a cause of dumbness than central lesions ; nevertheless cases are met with where hydatid or other tumours result in dumbness through pressure on the nerve itself. i. Dumbness from Lead Poisoning. — Among the paralyses arising from the slow effects of imbibition of lead is paralysis of the tongue, with consequent loss of articulating power. This defect is usually associated with grave impairment of other parts. Tbeatmemt. — The treatment of dumbness due to lead-poisoning will be best effected by elimi- nation of the poison by the administration of iodide of potassium, and the judicious employ- ment of galvanism to the spinal system. 6. Dumbness from congenital defects of the tongue or of the palate. — Various con- genital local lesions are met with giving rise to dumbness. Theatmbnt. — ^Many of these cases are reme- diable by surgical or surgico-dental help, fol- lowed by methodical teaching. 6. Dumbness from emotional lesions. — Dumbness occasionally arises from great emo- tional disturbance, such as great anger or sudden flight. Moreover, it is often met with, without tsuchmarked cause, in individual6,«specially of the female sex, having a highlv developed emotional life. Teeatment. — Oases of this kind are usually successfully treated by faradisation about the muscles of the neck ; the patient at the same time being encouraged to call his articulating power into action, and in proportion to his success the faradic current being discontinued. The moral treatment here indicated may bo greatly assisted by promoting the general health, and placing the patient under the best possible circumstances as to hygiene and moral disci- pline. 7. Dumbness from intellectual disorders. ^ — This is by far the most common cause of true dumbness. It may arise from idiocy or im- becility of a congenital nature ; from that which has been acquired early in life; or from dementia as the outcome of acute or chronic brain-disease in middle or .advanced life. Among the con- genitally feeble-minded, dumbness is » very frequent phenomenon. This arises from the association therewith of deformed mouths and highly-arched palates ; from defective power of co-ordination of the muscles of the tongue ; and from an inability to transform ideas into word- signs. In tjie most profound casesthere is such an absence.of ideas that language of any kind is not required, DUODENUM, DISEASES OF. 4or TuEATMENT,— The treatment of this kind of dumbness is one which requires great tact, patience, and energy; and the success will be commensurate with these aids. The physical health of the individual should be carefully attended to, so as to induce, by judicious food, frequent bathing, and warm temperature, the highest amoimt of nervous energy. The power of co-ordination should be sedulously cultivated by methodical exercises, especially of the hands, leading up to weU- devised tongue-gymnastics. He should then be taught monosyllabic sounds, by being shown tha object represented by the sound, whileheimitates the sound when watching the teacher's liptj. Having thus acquired the power of producing the word-sign by imitation purely, he is next taught to repeat it from memory when shown the object only. After nouns have thus been taught, the names of qualities and adverbial expressions shoiild be added, and in this manner articulate speech built up. Where the feeble-mindedness has been ac- quired after birth, the dumbness resulting there- from should be treated in a somewhat similar manner to that having a congenital origin, but the prognosis is not so good. Still more unfavourable is the forecast of dumbness when the result of dementia. J. Langdon Down. DtrODEBTTTM, Diseases of. — These may be considered under the heads of — 1. Functional disorder ; and 2. Organic diseases. 1. Functional disorder oi the duodenumis said to produce a form of dyspepsia, characterised by pain in the epigastrium and righthypochondrium two or, three hours after meals, vomiting, and the distant effects of ordinary dyspepsia — ver- tigo, headache, drowsiness, burning sensation in the soles of the feet and palms of the hands, &c. Imperfect chymification which attends ordinary dyspepsia may induce these symptoms by gene- rating products' which irritate the duodenum. The treatment is mainly that of disordered digestion. The bowels and the diet are to be carefully regulated ; and such remedies as alka- lies, bismuth, oxide of manganese, prussic acid, or hydrochloric acid, exhibited, according to the special requirements of each case. 2. Organic diseases. — These are inflammation ; ulceration ; and new-growths. a. Inflammation. — Synon. : — Duodenitis ; !Fr. Suodenite. — Jcute inflammation of the duodenum is usually of a mild catarrhal character. It either forms part of an enteri tis, or is an extension down- wards of a similar aflTection of the stomach. The ordinary exciting causes are exposure to cold, and irritating ingesta or acrid bile. Usually the symptoms of slight gastric catarrh — a loaded tongue, anorexia, nausea, vomiting of tenacious mucus — are followed by jaundice. When the duodenum is invaded there is said to be ful- ness and tenderness of the right hypochon- drium. As a rule, however, new symptoms are not set up unless the bile-ducts become ob- structed by mucus from extension of the catarrh into them, when jaundice supervenes without pain. The attack usually lasts a week or a fort- night, and, with suitable hygienic and dietefie 408 DUODENUM, DISEASES OF. treatment, passes safely off; it is, however, some- times followed by jaundice unusually prolonged, and, even when the bile-ducts are free, by pros- iration and wasting out of proportion to the mild- ness of the disease in itself. While catarrhal duodenitis does not present characteristic symp- toms, it is, however, usually suggested by pain- less jaundice following exposure to cold, catarrh of the stomach, and enteritis. Tbeatmbnt. — This consists in rest in bed, warmth, liquid diet, counter-irritation by mustard and hot poultices, and effervescing salines. Chronic inflammation, resulting in thickening of the mucous and submucous tissue, and even adhesion of the duodenum to adjacent organs is iisually associated with chronic ulceration, or with cancer of the duodenum, pancreas, liver, or other structures. Contraction of the duodenum produces symptoms of obstruction similar to those arising from stricture of the pylorus. b. TTloeration. — Perforatwig ulcer, similar to tliat of the stomach, is said to be more frequent in men than in women, and hardly ever to occur during childhood ; while it frequently follows severe and extensive burns and scalds. The ulcer, usually found in the upper horizontal portion, when recent has clean-cut edges free from swelling. The wall of the duodenum may be perforated, either without previous adhesion, being followed by the signs of general perito- nitis ; or .with adhesion to adjacent parts, such as the liver, the gall-bladder, the pancreas, the colon, the hepatic artery, or the posterior wall of the abdomen — into which ulceration extends to a variable extent. Cicatrisation may induce stric- ture of the duodenum or obliteration of the bile- duct. As a rule the symptoms greatly resemble those of perforating ulcer of the stomach ; more frequently, however, the disease is latent, and induces very obscure dyspeptiC' symptoms prior to fatal perforation. Jaundice is not more com- mon than in the similar affection of the stomach. In burns and scalds perforation seldom occurs before the tenth day. The duodenum may be ulcerated by the action of a gall-stone passing into it directly from the gall-bladder. ' e. New grovirtlis. — The most important of these is scirrhous cancer, which may involve the walls of the duodenum, usually by extension. It tends to produce obstruction, or it may set up chronic duodenitis, or block up the bile-duct, and thus give rise to jaundice. GrEOEGE Oliver. DTJBA MATUB, Diseases of. See Meninges, Diseases of. DUBATIOIT OF DISEASE, see Disease, Duration of. DTHAMOMETEB (Siva/iis, power; and fierpoy, a measure). Desckiption. — The dynamometer is an instru- ment originally invented by M. Duchenne, of Boulogne, for measuring and accurately recording the strength of the hand-grasp, and also for measuring the traction power capable of being exerted by other groups of muscles. , The result is shown by an index, which traverses a semi- circular dial bearing a scale graduated so as to DYSENTEEY. enable the observer to record the number of kilo- grammes which the applied pressure or traction represents. In practice this instrument has been principally employed for estimating the absolute or comparative force of the hand-grasp ; and in view of this restriction, Duohenne's instrument is needlessly complex. It has, moreover, the abso- lute disadvantage of being a little too broad, and of requiring too much strength on the part of the patient to move the index over the lower figures of the dial. A patient with a small amount of motor power, especially if the hand' is small, is often unable to set the index of this dynamo- meter in motion. A cheaper, simpler, and nar- rower instrument has, therefore, been devised by English makers, the index of which can bo moved by the application of a much smaller amount of power. This consists of a simple elliptical ring of steel, to the inner and anterior face of which is attached a brass semi-circular dial graduated with two rows of figures repre- senting pounds instead of kilogrammes.'' The compression of the steel ring, by lessening its shorter diameter, moves a met^l bar projecting from and sliding in a groove behind the dial, and this by rack-work communicates its move- ment to the index. Uses. — The dynamometer is a useful insteu- ment, inasmuch as it enables us accurately to as- certain the relative compressing powers of the two hands in eases of incipient or actually developed hemiplegia, and also' to learn in a positive and definite manner, from time to time, the amount of improvement or the reverse which may have taken place. Since the power of the muscles of the fore-arm and hand, like that of other groups of muscles, varies a good deal with the general state of health of the patient, the dynamometer is also capable of yielding valuable informa- tion concerning the strength of the patient, even where we have not to do with a case of paralysis. Any instrument which, in the place of fleeting and more or less vagne impressions made upon the mind of the practitioner at the time, enables him to make >i more accurate record in figures in his note-book, is a clear gain to practical medicine — more especially when its use involves no appreciable loss of time. H. Chaelton Bashah, PYS.2ESTHESIA (Sis, with difficulty, and luffBivoii.ai, I feel). — A term applied to impair- ment of any of the senses, but especially to that of touch. See Sensation, Disorders of. DYSCBASIA (Sis, dijacult or bad, and KpdiT.s, a mixture). A morbid condition of blood. This term signifies more than a disposition to disease ; it implies the presence of some general disease exerting its pernicious effects upon the blood. Hectic fever, septicasmia, and metastatio inflammations are diseased conditions referable to dyscrasise. A person sickening for a fever is the subject of a specific dyscrasia. See Bioon- Disease. E. Dodglas Poweh. DYSEWTEBY (S!is, with difBeulty, and HvTepov, an intestine). Synon. : Pr. Dyiintene] Grer. Bysenterie. Definition.- -A specific febrile disease,' charac- DYSENTERY. 109 terized by considerable nervous prostration and inflammation of the solitary and tubnlar glands of the large intestine ; sometimes ending in reso- lution, but frequently terminating in ulceration, occasionally in more or less sloughing or gan- grene ; always accompanied by tormina and tenes- mus, the latter being most marked when the disease is located in the rectum or lower end of the sigmoid flexure ; stools at first more or less feculent, later on yielding dysenteric products ■without much if any feculence, such as blood, mucus, slime, and gelatinoid exudation, or — as in the sloughing or gangrenous forms — like the washings of meat, and possessing a putrid or gangrenous odour, and so-called epithelial, ash- coloured, black, gangrenous, pua-infiltrated_ or tubular sloughs, chiefly consisting of tough, im- perfectly organised exudation, r .SliioLOGY. — In almost all, if not in all, situa- tions where malarious fevers abound, as in the vicinity of the swamps and sluggish rivers of tropical and sub-tropical countries, dysentery prevails in proportion to the intensity and fre- quency of these fevers. When, on the other hand, intermittents and remittents have been extin- guished by improved drainage and the conversion of marsh into cultivated land, it becomes equally unknown. In or near the tropics. Great Britain, Canada, the United States, and in many other parts of the world, its diminution has proceeded fari passu with the decrement of malarious fevers. There would, therefore, seem to be some intimate connexion between the causation of dysentery and intermittent and remittent fevers. Paroxysmal fevers interfere materially with the nutrition and functions of the digestive organs, and with the proper nourishment and constitu- tion of the blood. Violent congestion of the abdominal viscera is one of the special conditions of the different forms of ague. Both the liver and spleen are liable to temporary and repeated engorgement, and so in fact are all the organs which minister to gastric and intestinal diges- tion. Even where malarious poisoning may never have resulted in any of the various forms of periodic fever, it may impair the power of the organic nerve-centres and the muscular tone of the blood-vessels, thus disturbing the balance of the portal circulation, and leading to more or less permanent repletion or congestion. As the congestion is most embarrassing during diges- tion, interfering with the appetite, and the capacity for digesting and assimilating food, its repeated and prolonged existence must deterio- rate the quality and modify the quantity of such important secretions as the gastric juice, the bile, the pancreatic juice, and those fm-nished by the follicles of Lieberkiihn, and by Brunner's and the solitary glands. Crude alimentary prin- ciples are thus assimilated from the intestinal tract. The liver is especially liable to func- tional derangement from the stagnation and slowing of the portal circulation, and thus it happens that in dysentery hepatic impairment is almost an invariable accompaniment. Such being some of the abnormal conditions produced by the operation of malaria in its active or latent form upon the chylopoietio viscera, it is not surprising that, under the prolonged strain, cer- tain portions of thealimentaiy mucous membrane should break down. Why the solitary glands of the large intestine should be the special seat of dysentery, whilst the corresponding glands in the small intestine should, with few exceptions, escape, it is, in the present state of our know- ledge, impossible to say. The most that can be hazarded is, that the elementary structures of these glands take on morbid action through the operation upon them of a materies mnrhi derived directly from their blood-supply. That this poison exists in the blood may be inferred from the fact that constitutional disturbance invari- ably precedes and accompanies the earlier stages of acute dysentery. Unwholesome drinking-water is a fertile prox- imate and exciting cause of dysenteric disease. Bad and unwholesome food of whatever descrip- tion, by providing aliment incapable of being perfectly digested, may act in producing the disease. In like manner impure air may, by preventing the proper aeration and depuration of the blood, and by promoting the retention in it of Inassimilable material, light up dysenteric inflammation of the solitary glands. The transit of acrid and vitiated bile and other secretions poured into the digestive canal, often operates as fin exciting cause, and frequently determines a morbid action which might be otherwise righted by resolution, to advance to ulceration, sloughing, or gangrene. It is thus that many a simple but neglected case, scarcely at first distinguishable from diarrhcea — unless indeed every evacuation is most carefully washed and scrutinised — ends in destruction of large masses of the mucous membrane, and death, from the conjoint effect of exhaustion and shock from the separation of the sloughs. Indigestible articles of diet, which cannot be reduced by the juices of the digestive tract to a condition admitting of ready absorp- tion, may act as local irritants and exciting causes. Not only is this so in the earliest visible stage or that of active congestion, but it becomes much more susceptible of demonstration in the exudative and ulcerative phases of the disease, by the repeated investigation of the subjective and objective indications. Thus the aggravation of the tormina and tenesmus in adults and children is traceable to indiscretion in diet, or to the passage of undigested morsels of food, re- cognisable in the stools. Sudden vicissitudes of temperature from a high to a low range, or ex- posure to damp and cold combined, especially when the vital powers are physiologically de- pressed, by checking the excretory action of the skin and diminishing the cutaneous circulation, augment the portal congestion and excite dysen- teric disease. This is probably the reason why, in a large proportion of cases, the onset of the disease is ushered in towards midnight or the early morning. The influence of epidemic states of of the atmosphere in the causation of dysentery, signifies only that it is most prevalent at those seasons when malarious fevers are most abundant. A.S there is an intimate connexion between the existence of malaria and the prevalence of dysen- tery, it is not difficult to understand why, both as regards type and seasonal frequency, dysentery should bear a striking relation to the severity and seasonal prevalence of malarious fevers. Is dysentery a coniagious nr commnnicahh 110 DifSENTEEY. disease t — Whilst many of tlie older physicians held that it might be spread by contagion from person to person, it may be affirmed that the experience of most modem practitioners is alto- gether opposed to this view. There is no clear and unimpeachable evidence to demonstrate that it is propagated in the same way as typhus or smallpox. It may possibly be communicable, like typhoid fever, through air, water, or food — liquid or solid — charged with material -derived from the undisinfected and putrefying products of the disorder. Be this, however, as it may, the complete disinfection or destruction of the alvine evacuations should always be regarded as a sanitary measure of supreme importance. Anatomical Characters and Patholoqt. — The dysenteric process generally consists of a specific inflammation of the solitary glands (Parkes, Baly, and others). The Jirst visible change is congestion, the vessels surrounding and penetrating the capsules being turgid and en- gorged -with blood. The second change is aug- mentation of their contents from the accumulation of albuminous exudation, and enlargement ' from the size of a millet seed to a small shot' (Baly). The third change is, provided the inflammation advances, rupture of some of the capillaries in the interior of these little vascular glands, ex- travasatipn of blood,-with the area of the ordinary dark point on the free aspect increased. The fourth stage is now marked by atrophy and molecular disintegration of the free aspect of the capsular wall, and escape of its morbid gelatinoid blood- tinged contents into the canal of the intestine. This is the rule, butj in very exceptional cases, the capsule may burst through the attached por- tion, lighting up inflammation in the neighbour- ing connective tissue and muscular coat. In a large number of instances, the morbid process may stop short, under proper treatment, at any of the first three stages, and repair is then effected by resolution. In many cases the morbid action is cut short after the completion of the fourth stage, without further extension of the disease. The adjoining follicles of Lieberkiihn do not, in these cases, necessarily participate, to any great extent, in the diseased process. Under these conditions, when the -whole of the exudation has been expelled, the glands regain their tone and functions, and recovery — rapid and complet,e — ensues. It is not often possible to illustrate these conditions in the post-mortem room ; because, when death supervenes from dysentery alone, the ravages committed upon every structure of the mucous membrane are so extensive as to destroy the earlier physical phases of the disease. In some cases, however, which have died from intercurrent ajfections, the writer has been able to demonstrate the earliest stages successfully to nis students, at a period prior to the implication of Lieberkiihn's follicles, of -which the mucous niembrane is in great part composed, and to ex- hibit to them the gelatinoid exudation, termed by others ' gelatinous mucus,' free from or tinged with blood taken from enlarged and diseased solitary glands {Indian Annals of Medical Science, p. 190, No. xxiii., 1868). "Wlien, owing to neglect, to constitutional de- fect in spite of the most careful therapeutic and hygienic management, or to intensity or quantity of the specific poison, the disease is: not cond by resolution, the disintegrating or ulcerative pro- cess is developed. The whole of the solitary glands engaged perish. The ulceration involves the neighbouring tubular glands, leading to ulcers varying from the size of a mustard-seed to that of a florin or more, in depth generally extending to the submucous connective tissue, and not ia- frequently laying bare the circular lamina of the muscular coat, sometimes involving the longitu- dinal layer and perforating it as well as tho peritoneal coat, thus admitting of the extravasa- tion of the contents of the -bowel into the peri- toneal cavity and lighting up peritonitis, which, if general, is invariably mortal, but which, if local and confined to the close vicinity of the perforating ulcer, is not necessarily so. The ulcers vary in appearance, size, and shape. They may be mere abrasions without mach loss of structure, minute though penetrating rather deeply into the submucous connective tissue | irregular, serpentine) or rodent, with here and there' portions of the surrounding mucous mem- brane undermined and patulous ; transverse, embracing partially, or completely; the entire circular outline of the mucous membrane ; circa- lar, or oval, with regular and oven margins ; or tuberctdar, involving the whole substance of the mucous membrane, looking as if they, had been punched out of it. These ulcers^ as generally observed in the post-mortem room, are free from sloughs, and present a pale ashy appearance. Sometimes they are of a vermilion or purple colour, from active or passive congestion. Tliey are often covered with flakes of tenacious lymph or exudation, and this may sometimes be seen spread over the neighbouring mucous membrane. The floors of these ulcers are usually formed, by inflamed and thickened submucous areolar tissue ; but sometimes this has all been destroyed, and then they are constituted of the muscular coat, thickened and infiltrated, by inflammatory pro- ducts ; and when the muscular structure has itself yielded to the ulcerative process, they are made up of congested and swollen peritoneum which, as already stated, occasionally becomes perforated. When the ulceration proceeds solely by mole- cular disintegration massive sloughs are not observed. But when, as not uncommonly happens in asthenic, malarisi-stricken, tubercular and worn-out constitutions, tissue-death occurs fli masse, at an early period of the attack, slough- ing of, the mucous membrane, together with portions of the muscular coats, or gangrene, is to be seen. These sloughs, or gangrenous portions of tissue, may be limited i^ extent. Some or all of them may be successfully detached during lifO) and can be identified as they are examined from time to time in the stools. In the post-mortem room they may be found partly detached and lying loose, mixed with the fluid contents of the bowel, or attached more or less firmly, sometimes compact, nodular, ecchymosed, gray or ohve- ooloured, green or yellow and pus-infiltrated, black, flaky, shreddy, shaggy, flocculent liks pieces of teased cotton-wool, or ragged and stringy. In the truly gangrenous dysentery, the mucous and muscular coats are enormously thickened, and large portions are found gaagre- DYSENTERY. 411 nous, varying in colour from a pale olive to purplo or black. These appearances and conditions may be restricted to the cseoum and ascending colon, or to the sigmoid flexure, but sometimes they are co-extensive with the internal structure of the large intestine from the ileo-colio valve to the anus. When the ileo-oolio valve becomes de- stroyed, invagination of the lower end of the ileum into the csecum sometimes happens, causing intestinal obstruction, Occasionally many inches of the gangrenous mucous membrane, with or without the muscular coat, is either found hang ing loose in the lower part of the gut, or in pro- cess of being detruded from the anus. In ordinary acute dysentery, advancing to ulceration or sloughing, repair is, doubtless, accomplished, as a general rule, by granulation and cicatrisation; This process can be readily observed in dysenteric lesions of the mucous membrane of the lower end of the rectum, and in healing of the surgical ulcer within the verge of the anus. The reason why repair is frequently accomplished so slowly is because, owing to the irritation caused by the exalted vermicular con- traction of the gut and the passage of flatus, faeces, and other products, it is- impossible to command the physiological rest necessary for speedy and substantial granulation and cicatri- sation. Unless the destruction of tissue is very great, the contraction due to cicatrisation does not occasion much future inconvenience. But if it embraces a large portion of or the whole circum- ference of the mucous membrane, the subsequent contraction may producedangerous narrowing of the calibre of the gut, or stricture of the sigmoid or rectum. The thickening and contraction, especially in the attenuated victims of chronic dysentery, can be identified by physical exami- nation. These constrictions are frequently the mechanical cause of constipation and faecal accumulations. There is no valid reason for believing that, in true dysenteric ulceration, the lost tissue is ever actually reproduced. When the ulcers have been small, the contraction following repair issuificient to bring the follicles of Lieberkiihn on all sides into close juxtaposition. And this it is which has given rise to the impression among some pathologists, that the lost tissues have been renewed by a process of development and growth. But whenever the ulcers have been too large to admit of obliteration, microscopical examination shows that they have been bridged over by cica- tricial tissue, devoid of solitary and tubular glands and sparingly supplied with blood-vessels and absorbents. In addition to the above anatomical characters, the mesenteric glands are generally found to be enlarged, and as an accompaniment or sequel, organic disease of the liver op abscess is not infrequently discovered to complicate the disease. Symptoms. — Every attack of acute dysentery is preceded by disordered digestion and constitu- tional disturbance, indicated by loss or capricious- ness of appetite and furred tongue, constipation alone or alternated with looseness.dryness of skin, occasional chilliness and general malaise, with sljght rise of the evening temperature. These signs may he viewed as cotemporaneous with the progress of the morbid action going on in the soli- tary glands. As the disease advances, there i; more marked chilliness, succeeded by distinct feverishness. If the bowels have been confined, they now act spontaneously— expelling, at one or more acts of defsecation, almost the whole of the contents of the large intestine. If they have beep loose, with or without aperient medicines, the fecu> leuce is not so great in quantity., But in either case, beyond a little mucus, there is not as yet any discoverable dysenteric product in the stools. Prior to this conservative evacuation . of the bowels, the febrile excitement sometimes runs high ; there is thirst, bad taste in, the month, flatulency, a variable amount of nervous and mtiscular debility, griping, an accelerated and irritable pulse, restlessness, disturbed, sleep, oi actual insomnia. During, and immediately after, each evacuation, there is tenesmus or painful Btraining^most intense in those cases where the disease is located in the descending colon, sig moid fiexure,and rectum. The stools are offensive, but there is nothing at this stage pathognomonic in their odour. If, as frequently happens in private practice, the patient comes under treat: ment at this period, a small dose of castor oil guarded by laudanum,or a full dose of ipecacuanha, with absolute rest in bed and bland liquid nourishment, is sufficient, in a certain proportion of cases, to put a stop to the morbid action, and to promote cure by resolution in from twenty- four to forty-eighthours. When, however, the disease persists, tlie symp- toms continue in an aggravated form. The tormina and tenesmus become intensified ; the desire to go to stool is more frequent, and to remain on the stool or bed-pan more irreisistible and enduring, especially if the disease Ije concen- trated in the sigmoid £exure or rectum. In rectal dysentery, there is dysuria, frequent .micturition, and sometimes retention, from spasm due to reflex action, necessitating catheterism. The consumption of solid food — even of the most digestible kind — provokes and aggravates the tormina. The griping and .tenesmus are now so intensified in degree, and. increased in frequency, that each recurrence of them produces much depression and exhaustion, and a pinched and anxious expression of thp countenance, with aug- mented frequency aud weakness of the. pulse. There is abdominal tenderness. During the acme of the tormina, the patient experiences dif- ficulty in localising this tenderness. He will then declare that he feels agonising pain over the greater part of the abdomen, with or without the application- of pressure. , But in the absence of the tormina, careful palpation wiU enable the practitioner to localise it in those portions of the intestine above the rectum affected by dysenteric inflammationj At, this stage the tumefaction of the walls of the gut is seldom great enough to be distinguished through the abdominal parietes. The scanty stools are now characteristic, consist- ing of mucoid exudation tinged with blood, or bloody, mucus or slime from the inflamed tubular glands, with.isolated portions of. gelati- noid exudation, more or less coloured with blood from inflamed and ruptured solitary glands, and with little or no feculence. These conditions are cotemporaneous with the rupture of the affected solitary glands, and a highly inflamed state of 412 DYSENTEET, the adjacent follicles of Liebertiihn, as well as of the subjacent and intervening conneotive tissue. The mnaeular tissue, though not yet ne- cessarily inflamed, is nevertheless hypersesthetic. It is this hyperseathesia which has more to do with the production of the agonising tormina than the diseased glandular organs implanted in and forming a constituent portion of the mucous membrane. These are the symptoms presented IE a goodly number of cases met with in private practice, and in a smaller proportion admitted into hospital. The disease is said to have lasted from two to six or -eight days. In uncomplicated cases occurring in tolerably good constitutions, they generally yield, without extension of the mischief, to rest, bland liquid food, and full doses of ipecacuanha. In cases which have been neglected or aggra- vated by indiscretions in diet and drink, or by diathetic or other defect of constitution, the dysenteric process passes on to ulceration. If the patient has not been brought under proper thera- peutic and hygienic management, ths tormina, tenesmus, local tenderness, and hardening of the superimposed abdominal muscles are augmented. Tlie calls to stool are more frequent and painful. The urine is scanty and high-coloured, and is surcharged with lithates and biliary pigment. The stools mainly consist of the. foreign pro- ducts already described, but in greater quantity, are now possessed of a peculiar sickly smell, and yield portions of exudation in masses of greater or smaller size, simulating sloughs, but which, on microscopical examination, are seldom found to afford positive evidence of dead tissue-elements. Unless the disease bends to treatment, it may terminate in sloughing. This may be restricted or extensive. Death of portions of the mucous membrane is always accompanied by vital depres- sion or well-defined muscular and nervous pros- tration, cardiac enervation, and an accelerated and feeble pulse. In some cases, tissue-death en masse happens at an earlier period, even before the rupture of the solitary glands, and the sloughs can be discovered in the stools in from the eighth to the thirteenth day. The acme of vital prostration is manifested during the detach- ment of the sloughs, when the exhaustion is often much increased by haemorrhage. Improve- ment in the strength, volume, and slowing of the pulse, and in the expression of the countenance, the comparative relief from tormina and tenes- mus, cleaning of the tongue, and the substitution of feculence for dysenteric products in the stools, signify, in these cases, the probable cessation or turning-point of the disease. The converse im- plies that the sloughing is extending, and a suc- cession of sloughs of various kinds, with or without muscular structure, continues to be passed, which, in the process of separation, are accom- panied by much bleeding, especially in patients poisoned by malaria or afflicted with the scor- butic or hasmorrhagic diathesis. The abdominal tenderness and hardening of the parietal muscles are marked during the separation of the sloughs. The affected portions of the colon can be felt to be swollen, doughy, and 'puddingy' (Chevers). The skin, in unfavourable eases, becomes clammy, features and eyes shrunken, body emaciated, appetite in abeyance, thirst great and distiwKing, tongue dry and brown, pulse feeble and runnmg, and stools extremely offensive, bloody, slimy or watery, with varieties of sloughs and exudation. The sensibility becomes so blunted that the stools are passed without much pain— oftea involuntarily; and the patient eventually dies from sheer exhaustion from the extension of the sloughing, or the end may be accelerated ty per- foration of the bowel in one or more places, leading to extravasation of some of the contents of the intestine into the peritoneum, Kid general peritonitis. Sometimes, from the commencement of an attack, or during the conrse of acute dysentery, rapid sloughing, passing into gangrene, of large patches of mucous membrane, attended by increasing prostration and soon merging into collapse, forms the chief pathological condition. As tbis extends until, in many instances, it in- volves almost the whole of the mucous mem- brane, submucous tissue, and muscular structure, it is characterised by intensified collapse. The tormina and tenesmus, at first excruciating, sud- denly disappear, to the delusive relief of the sufferer. Until the gangrene has spread to s great extent, the stools contain a large quantity of slime, blood, peUicular-looking exudation, and much gelatinoid exudation; but as the living mucous membrane becomes diminished, these products also decrease, and, in their room, we notice a watery product of a dark purple or black colour, resembling the washings of meat, giving off an incomparably offensive and gan- grenous odour. To the naked eye, and on washing, these stools seem to be absolutely devoid of feculence. They yield a granular sediment of a black colour — gangrenous dibm blackened by the combination of sulphur with the iron of disorganised cruorin. The abdomen, at first doughy, becomes tympanitic and free from pain on pressure, and the surface cold and clammy ; the countenance resembles the haggard and sunken appearance presented during the algid stage of cholera ; the tongue is dry, brown, and fissured; the pulse is thready and rapid; food and medicines are rejected, the dejecta are passed involuntarily, perception is blunted, de- lirium supervenes ; and the patient' at last succumbs, worn out and exhausted, in from the sixth to the thirteenth day, according to the range and severity of the disease and the con- stitutional power of the patient. Chronic Dysentery. — This is sometimes the result of acute dysentery, in spite of the most appropriate management, in persons poisoned bjr malaria and weakened by fatty or waxy degene- ration of the spleen or liver, or both, and in strumous or scorbutio constitutions; The d;js- crasia may be so pronounced that the material exuded is incapable of healing up the ulcers by granulation and cicatrisation. The ulcers are repeatedly disturbed by peristalsis, the passage of flatus, faeces, undigested morsels of solid food, and the acrid unutilised secretions of the liver, stomach, and pancreas. Thus they are liable to become irritable from renewed congestion and inflammation. The muscular coat participates in the excitement and becomes infiltrated with exudation, which eventually becomes organised and leads to thickening. The floors and sidei of Ihe ulcers are constitutad of unhealthy struo- turs. The difficulty thus experienced in effectr ing repair is augmented. _ In other eases the intestine becomes atrophied, attenuated, and transparent. The stools are made up of serous exudation, slime. Wood, and sometimes of puri- form material, with feculence generally unformed. Almost erery stool will he found on washing to contain dysenteric products. The appetite is uncertain ; the tongue often clean, shining, and devoid of epithelium ; the pulse weak and irri- table; and the abdominal tenderness easily localised. Thickening can often be detected. Tormina are always present, and unless the disease he confined to the csecum or ascending and transverse colon, there is tenesmus. Multiple abscesses of the liver frequently supervene and carry off the patient, or after months or years of suffering he may perish from inanition and exhaustion, or from intercurrent disease. Complications.— Acute dysentery is frequently complicated by the various forms of malarious fever, typhoid fever, the tubercular or thehsemor- rhagic diathesis, purpura, scurvy, hepatic and splenic enlargement, malarious cachexia, or alj- scess of the liver ; and in children by dentition. In every case of dysentery the strictest atten- tion should be paid to existing complications. In patients inhabiting marshy districts, and those following a seafaring life, the gums should be carefully scrutinised and the cutaneous sur- face examined with a view to ascertain the free- dom or otherwise from purpuric or scorbutic taint. The history of the patient should be gone into, in order to make out the probable diathetic proclivities — acquired or hereditary. Sequeue. — That abscess of the liver, single or multiple, frequently follows acute and chronic dysentery, is indisputable; but whether as a result of the general condition existing, or of local pysemic poisoning or embolism originating in the veins within the area of the ulcers, is still an open question. Dysentery sometimes termi- nates in permanent thickening of the parietes of the gut with eventual contraction or stricture, causing constipation, fseoal accumulation or ob- struction. "When the seat of stricture can be reached, as in the lower part of the rectum, much relief can be afforded by simple incision and sub- sequent dilatation by means of bougies. Fissure of the anus, or ulcer within the verge of the anus, is a common sequel. Once diagnosed by exami- nation of the stools and by means of the speculum, it' admits of speedy relief by incision end after- Surgical management. ■Diagnosis. — From diarrhcea, dysentery can be diagnosed by the abdominal tenderness, tormina, tenesmus, and the existence of dysenteric pro- ducts in the stools. Dr. Edward Goodeve, late Professor of Medicine in the Calcutta Medical College, was the first to carry out the practice of washing the stools in dysentery and diarrhcea. The stools are first examined as they lay in the stool-pan. Water is then added in considerable quMitity. Aftera short interval, to allow the dysen- teric products to sink to the bottom, the super- natant fluid is gradually poured off. The washing is repeated until the foreign products remain clean and destitute of much smell. When these products are putrescent, or perhaps in all cases. DYSENTERY. ^^'^ it is convenient to wash the stools with a solu- tion of carbolic acid or other colourless disin- fectant. Dysentery is diagnosed from fiseure or ulcer of the rectum by the fluid or loose charac"- ter of the stools, with dysenteric products, and by the absence of ulcer, aa determined by examination by means of the anal speculum, Pboqnosis. — Favourable. .The follovfing are to be regarded as fiivourable features in the prognosis of any given case : — The ordinary un- complicated form of acute dysentery ; early subsidence of the constitutional disturbance ; a steady, firm and strong pulse, with diminishing frequency and iucreasing power; moderate abdominal tenderness; absence of tympanites; a placid and normal expression of countenance ; absence of sloughs or putrescent matters in the stools ; early subsidence of tormina and tenesmus with the appearance of feculence and the co- temporaneous decrease of dysenteric products ; return of appetite and power of digesting and assimilating food; and the absence of inflam- matory or suppurative mischief in the liver. Unfavourable. — Unfavourable features, on the contrary, are : — The persistence of an elevated temperature ; quick piise with increasing feeble- ness ; sudden freedom from tormina, tenesmus, and abdominal tenderness, With great vital depression or collapse; doughy thickening of the colon with dulness on percussion where there should be resonance ; sudden increase of abdo- minal tenderness, with hiccup, nausea, vomiting, and great nervous prostration, tympanites, and peritonitic pain with constant hardness and tension of the abdominal muscles ; increase of putrescent and gangrenous products in the stools like the washings of decomposing flesh ; exces- sive haemorrhage from the bowel ; bleeding from chapped and fissured lips, gums, and mouth; harsh, dry, black or glazed tongue; delirium; picking at the bed-clothes; scantiness or sup- pression of urine. TiaGATMENT. — Should an aperient be required in the congestive, exudative, or ulcerative stages of acute dysentery, or in sudden relapses super- vening upon chronic forms of the disease, the readiest, simplest, and most painless is a tepid water enema of from two to four pints. After the operation of the enema; or immediately the patient presents himself snffenng from any of these dysenteric conditions, in those cases where no preliminary aperient is indicated, a turpen- tine epithem or mustard plaster should be ap- plied to the epigastrium for twenty minutes. At the same time, from twenty grains to a drachm of ipecacuanha suspended in two drachms of syrup of orange-peel and four drachms of water, or in half an ounce of infusion of camomile, with ten grains of carbonate of soda or bismuth, or simply made up into conveniently sized pills, should be administered. The recumbent posture, with the head lower than usual, should be enforced. Liquids should be resisted as much as possible for an hour or two. Thirst may be quenched by sucking pieces of ice, or, when this cannot be procured, by cold water in teaspooneful at a time. Nausea will probably occur ; perhaps, in some eases, retching and vomiting. But as the vomit- ing is exceptional, and when it does occur seldom happens before the lapse of an hour after the 414 exhibition of tho drug, the ejected matter usually consists of small quantities of gastric secretion. Should the ipecacuanha be rejected, the dose should be repeated as soon as the stomach has been tranquillised. It 'will be found beneficial to time the large doses, so as to allow t! one being given night and morning so long as their use is considered necessary. The signal for the relinquishment of these doses is freedom from tormina and tenesmus, with the occurrence of refreshing sleep, feculent, bilious, or ipecacu- anha stools, and restoration of the primary pro- cesses of assimilation. If no great amount of disorganisation of the mucous membrane has taken place, these favourable changes are fre- quently noticed after the administration of the first or second dose, and even if undoubted ul- ceration has set in, they are generally discerned on the second or third day, or earlier, In either case the drug should be abandoned, as the dis- appearance of the tormina and tenesmus and the absence of mucus, blood, and slime from the stools indicate the cessation of dysenteric inflam- mation, and that the affected portions of the bowel have been placed in the most favourable condition to undergo cure by ' resolution,' if the case has not proceeded to ulceration, or by * granulation and cicatrisation,' if xdceration or even sloughing has already taken place. Chalk- mixture with hyoseyamus and astringents is now quite sufficient to wind up the cure. In some cases ferruginous and bitter tonics are demanded, to givfi tone to thedigestive organs, and to improve the condition of the blood. Counter-irritation by moans of turpentine epithems and mustard plasters to the abdomen, or fomentation, are valu- able adjuncts in the management of the disease. The diet should consist of chicken broth, beef- tea, essences of chicken, mutton, or beef ; sago, arrowroot, or tapioca; and small quantities of port wine or brandy. During the active period of the disease all food should be given in a liquid form. The disturbing effect of the ipe- cacuanha given as above directed is only tem- porary. Abundance of time is, therefore, avail- able between the large doses for the digestion and assimilation of liquid food. As the stools become more feculent and consistent, solid food in the shape of tender chicken, lamb, and mut- ton, with biscuit and bread, light sago, rice, or tapioca pudding should be allowed. Potatoes and other vegetables should be avoided until the tone of the digestive system has been fully re-established. When the dysentery is compli- cated with a purpuric or scorbutic condition of the blood, the administration of the juice of the grape, orange, pomegranate, lime, and bael sherbet are essentially necessary as dietetic rather than therapeutic agents. Opium by the mouth is seldom required. When swallowed it ' looks up ' the secretions of the liver, pancreas, and alimentary mucous mem- brane, rather favouring than reducing the inflam- mation of the solitary and tubular glands. These bad effects counterbalance the benefits derived from the sleep, diminution of peristaltic action, and temporary decrease of tormina and tenesmus consequent on narcotism. This ex- plains why the real character of the disease is often completely masked by opium, and why DYSENTERY. apparent amendment is taking place, whilst de- structive ulceration and sloughing of the mucous membrane is rapidly extending. As ipecacuanha speedily brings about all the good without any of the evil effects of opimii,this narcotic, in any form, excepting as an enema or suppository to relieve tenesmus, particularly in sigmoidal or rectal dysentery, is not only superfluous but in- jurious. There is less objection to uniting the ipecacuanha with such remedies as are acfaow- ledged to possess the power of lessening the irri- tability of the stomach, and of increasing its tolerance of the drug, without interfering with the functional activity of those organs whoso secretions we are endeavouring to promote with a view to rectify the disturbed balance of the portal circulation. On tho contrary medicinal of this order may be beneficially associated irith ipecacuanha — such as carbonate of soda, bismuth, chloroform, camphor, and hyoseyamus,!* When dysentery occurs in pregnant women, large doses of ipecacuanha are not contra-indi- cated ; Deoause, if the disease be allowed to pro- ceed (which is more likely to happen under the old than the ipecacuanha treatment) abortion or premature labour is almost certain to follow; and when such a complication supervenes, in the later months of gestation, the mortality almost- surpasses that of amy other disease. When the dysenteric inflammation is summarily put a stop to by the ipecacuanha, abortion or premature labour is prevented. IJnder the opiate method of management, premature labour is not averted, but, in the majority of cases, occurs at the.acmj of the disease, when the sloughs are being thrown off; and the patient succumbs to the conjoint shock to the system. In dysentery complicated with pregnancy opiate enemata to relieve irrita- tion in the rectum are more essential and per- missible than under other circumstances. In the acute dysentery of children ipecaeuanha is invaluable. For a chUd of six months a grain, and for a child of one year two grains, should be given with an equal quantity of carbonate of soda, night and morning, until the tormina, tenes- mus, and sUmy and bloody stools are replaced by relief from pain and by feculent evacuations. It will not often be necessary to continue the drug beyond two or three days at a time. But it should be recollected that tho disease adheres with greater tenacity to children than to adults ; and although we observe that ipecacuanha has an im- mediately beneficial effectin diminishing the blood, mucus, slime and frequent stools, still we find that dysenteric or slimy motions with undigested food continue to pass. In that case the ipecacu- anha, combined witi chalk, bismuth, carbonate of soda, or aromatic powder, should be repeated, once or twice a day, for a certain period, till healthy evacuations are restored. The gums must be lanced when necessary} turpentine liniment or stupes may be applied to the abdo- men ; weak chicken-broth or' arrowroot should be temporarily substituted for milk ; and, above all, food must be given in small quantities at a time, and at regularly stated periods. From the age of one year the dose is regulated by adding one grain for each additional year of age up to eighteen, when the doses indicated for adiito should be employed. DYSENTERY, 4IS In oases -where evident malarious taint per- vades lie system and complicates acute dysen- tery, ^sulphate of quinine is indispensably necessary. A scruple of the antiperiodic ■will be most speedily absorbed if dissolved in water acidulated with sulphurio acid, and the exhibi- tion of this may precede by an hour the first dose of ipecacuanla. Ten-grain doses should be given midway between the large doses of ipeca- c-iinha, or during abatement of febrile excite- men*-, mtil th» feverish symptoms have been subdued. Quinine here is quite as important as ipecacuanha, for, until it has successfully checked the disturbing influence which malarious poison- ing exercises upon the eapillaries of the portal and general circulatoiy systems, the good effects which ipecacuanha produces are only temporary and incomplete. The mildest febrile exacerbations of a> miasmatic origin re-excite dysenteric action, and thus undo the good effected by the action of the ipecacuanha. Hence, the urgent necessity for removing without delay every vestige of masked or active malarious fever complicating dysentery. No drug enables us to accomplish this object so safely and so quickly as the disul- phate of quinine in largo doses. When ipecacuanha fails to preserve the life of the patient, its failure may be generally attri- buted to— (1) coexistence of abscess of the liver; (2) unchecked malarious poisoning; (3) per- manent enlargement of spleen or liver, or both ; (4) irretrievable constitutional cachexia ; (5) Addison's disease of the supra-renal capsules; (6) morbus Brightii ; (7) phthisis or tubercu- losis ; (8) strumous disease of the mesenteric glands; (9) peritonitis with or without per- foration of the gut; or (10) the existence of ex- tensive sloughing or gangrene. The advantages of the ' Ipecacuanha Treat- ment ' (for the revival of which the profession are indebted to Mr. Scott Docker, of the 2nd battalion of the 7th Eoyal Fusiliers, stationed at the Mauritius, — Lancet of July 31 and August li, 1858) in the congestive, exudative, and .ilcerative stage of almost every form and type of acute dysentery, as well as in the acute at- tacks supervening upon chronic dysentery, may be briefly stated to consist in (1) its simplicity, (2) its sitfety, (3) its certainty compared with any other method, (4) the promptitude with which the inflammation is stopped, (5) the rapidity with which repair takes place — (o) by reso- lution or (i) by granulation and cicatrization, (6) conservation of the constitutional powers, (7) abbreviation of the period required for con- valescence, (8) decrease in the frequency of chronic dysentery, (9) decrease in the frequency of abscess of the liver, (10) diminution of mor- tality to cases treated — all of which are accom- plished, (a) without local or general blood- letting, (6) without salivation, (o) without calomel and irritating purgatives, and (d) with- out opiimi by the mouth. Ipecacuanha in large doses may be said to fulfil many important indications. It produces (1) all the benefits that have been ascribed to blood-letting without robbing the system of one drop of bbod, (2) all the advantages of mercurial and other purgatives without their irritating action, (3) all the good results of antimonials and sudorifics without anjr of their uncertainty, (1) all the euthanasia ascribed to opium without masking, if not aggravating, the disease whilst the mischief ia silently accumulating within. Thus, we possess in ipecacuanha a noti-spoliative antiphlogistic, a certain chologogue and imirritat- ing purgative, a powerful audorifie, ani a harm- less sedative to the heart and the muscular fibres of the intestines. The objections which have been urged against large doses of ipecacuanha in dysentery are, ^«<, its 'depressing influence' kept up by nausea and vomiting ; and, secondh/, that it is liable to set up ' uncontrollable voSiiting.' First, the depressing power, nausea, and vomiting have all been over-estimated. Nausea is only a, temporary and evanescent effect. Vomiting is an exceptional occurrence ; and even when it does supervene, it seldom lasts long. As much nourishment, therefore, as may be required to support the strength can be al- lowed in the intervals between the large doses of ipecacuanha. But what contributes more to the conservation of the patient's stamina and to the prevention of depression or asthenia, is the speedy cessation of the dysenteric process accom- plished by the drug, followed by refreshing sleep and the power of digesting and assimilating nourishing food. Such remarkable results as these soon reconcile any patient suffering from dysentery to an otherwise disagreeable remedy. Secondly, when uncontrollable sickness and vomiting succeed the employment of this drug in the manner already recommended, the exist- ence of one or other of the serious conditions previously enumerated may be more than sus- pected. In the absence of these complications, unmanageable vomiting is seldom if ever wit- nessed. Hence, in a preponderating majority of the cases of dysentery met with this ob- jection is quite untenable. The truth is that every physician who has used ipecacuanha in heroic doses soon learns that depression of the vital powers from it is not to be feared, and is surprised at the small amount of vomiting that follows its administration, and at the unexpected ease with which the stomach tolerates its presenca When dysentery becomes chronic no time should be lost in counselling removal from a malarious to a non-malarious and mild climate. A sea voyage — provided easily digestible food can be secured — is often attended by the hap- piest results. To men so afflicted 'the salt ration,' as remarked by Dr. Maclean, ' is simply destruction.' The clothing should be warm, and flannels always worn around the abdomen ; Dr. Maclean also recommends 'the use of a water belt over the abdomen for some hours daily. This acts as a fomentation, and the steady uniform pres- sure it maintains seems to favour the absorption of the fibrine efifused between the intestinal coats. If there be much uneasiness about the fundament, a water compress over the anus affords more relief than opiate enemata.' The food should be chiefly concentrated soups, milk and lime-water, and sago, cornflour, arrowroot, &c., egg-flip with poit, sherry, or brandy; or, if solid food can be digested, the tenderest chicken lamb, or mutton, with bread and biscuit, may bo allowed. Beyond airing in a carriage or chair, no 416 DY6ENTEKT. exeroiseshould be attempted. Thepositionshould generally he recumbent or semi-reoumbent. The erect position excites peristaltic action, and thus disturbs the physiological rest required to facili- tate the repair of the ulcers. Antiscorbutic juices should be given where there is the least taint of scurvy or purpura. Frequent blistering does much good. All forms of counter-irritation are beneficial. Gallic acid, acetate of lead, sulphate of copper, nitrate of silver, are reputed to act beneficially. Dr. Maclean's favourite remedy, 'particularly in men returning from tropical regions, ansemlo from loss of blood and the de- praving influence of malaria, is the solution of the pemitrate of iron. Under this remedy the whole system often rallies wonderfully, the con- dition of the blood improves, colour returns to the blanched cheek, the stools become more natural and less frequent, the appetite improves, and digestion is more perfectly performed. The citrate of iron and quinine may after a time be substituted.' As nearly all chronic cases are underlain by a malarious taint, quinine should form an important element in the therapeutic management, and the greatest care should be taken to secure for the residence of the patient a climate at once mild and temperate and fi-ee from suspicion of malaria. Bathing during con- valescence is an efficient and welcome au3aliary. Tepid or warm baths medicated with Tidman's sea-salt or with nitro-mnriatic acid act in stimu- lating .the secreting function of the skin. But it will often happen that, in spite of the most careful dietetic, hygienic, and therapeutic ma- nagement, no substantial progress towards the repair of the ulcers is made, and the patient eventually dies, worn out from suffering and the asthenia consequent literally on inanition. Joseph Kwabt. DYSIDEOSIS (Sis, with difficulty, and iSpfis, sweat). — This is a disorder of the sweat- follicles hitherto confounded with eczema, and first differentiated therefrom and accurately described by the writer. It occurs in winter as weU as in summer, and often in those who per- spire freely ; and it attacks the hands chiefly, and especially the interdigital and the palmar sur- faces. The disease is characterised by the development of vesicles, which are not formed in the usual way in the rete, but are distensions of the sweat-apparatus by sweat secreted in excess, and' which fails to find its way outward free upon the surface. These sweat-vesicles are at first situated beneath the level of the skin, and indeed appear as little boiled sago-grains im- bedded deeply in the substance of the skin, and when once seen arc readily recognised again. If pricked, a little sweat oozes out. In the earliest stage the reaction of the fluid may be acid, but it soon becomes alkaline from admixture of seros- ity. These vesicles are distinct the one from the other at first, and are scattered about the inter- digital surfaces or the palms, or they may be grouped. In some cases their fluid contents dry away, and a little dryness and perhaps slight degeneration follow. They may enlarge and be- come prominent upon the surface, or run together mto bullae, and if the sweatweoretion is free, large bullae may form. Usually the cuticle becomes DTSUEIA. white and opaque from maceration in the fluid which collects beneath it ; and subsequently it peels off in a membranous manner, leaving be- hind, however, a dry reddened surface, but not a discharging one as in eczema. One or both hands may be affected ; and the feet may also be attacked. The disease occurs in connection with nervous debility. It may be attended with much itching or burning pain ; and may be aceompa. nied by miliaria. Anatomical Chaeaotebs.— If a portion ol skin be excised and examined in the early stage of the disease, it will be observed that there is no true dermic inflammation, but that the mor- bid changes are limited to the sweat-apparatus as the writer has shown {Pathological Sodetifa Transactions, 1879). The sweat-gland-coila are congested, and the results of such congestaon are also seen in the duct-walls as they run upward to the Malpighian layer, where the vesicles are formed. In the early condition the sweat- ducts are dilated, and choked by epithelial debris, and gradually this portion and the rete layer immediately outside the ducts, dilate into vesioulations under the pressure of the fluid poured out into the tube. In later stages the effusion is so free, and the distension of the tis- sues so decided, that the nature of the original formation of the vesicles is not recognised, and the vesicles may simulate those of eczema, save that the amount of inflammatory produojs is less, and there is no distinct connection between vesicles and engorged papillary vessels beneath. In the earlier stages of the vesicles, however, ducts can be distinctly traced entering the vesi- cles from above and leaving them from below, which conclusively proves that the vesicles are formed in connection with the sweat- apparatus. TEEATMEifT. — This oousists, internally in ex- hibiting diuretics, to be followed by nervine tonics according to circumstances, and locally in the use of soothing and astringent applications. TiLBUBT Fox, DYSMENORKHtEA (Sis, with difficulty; (tiji'i a month; and pem, I flow. — ^Difficult and painful menstruation, 3ee Mekstbuatios, Dis- orders of, DTSOBEXIA (S"s, with difficulty, and opefis, the appetite). — An obsolete term for im- paii'cd or depraved appetite. See Appetite, Disorders of, DYSPEPSIA tSis, with difficulty, and jrejrTw, I oonooot). — A Synonym for ind^estion. See Digestion, Disorders of. DYSPHAGIA (Sit, with difficulty, and tjayii), I eat). — Difficulty in swallowing. Sm Deglhtition, Disorders of. DYSPHONIA (Sis, with difficulty, and ^loini, the voice). — Difficulty in producing vocal sounds, so that the voice is more or less en- feebled. See Voice, Affections of. DYSPN of the greatest importance to keep the meatus sedu- lously free from secretion, and this occasionally is not a very easy matter. 2. Changes in cartilage. — Another condi- tion, in which the external passage becomes sub- ject to partial closure, is shrinking of the carti- laginous part of the meatus. This again, is a complaint of old age, and is attributable to no known cause. It is readily relieved by the patient wearing a piece of silver tube, to keep the passage patent. 3. Bony growths in the osseous part of the canal present two entirely distinct phases ; one in which, beyond the enlatgement of bone, there is no discoverable disease, and no impairment in hearing power ; the other where the growth would seem to owe its origin to some irritation. In the first case, the enlargements are very frequently symmetrical in either ear, and syn- chronous in their growth. So exactly is this so, that often where they exhibit three curves in one part of the bony canal on one side, the curves will be found to be precisely similar in size °jid position in the other ear. As the enlarge- 27 ments are not attended with pain, the patient will obviously be quite ignorant of his con- dition, until his attention is directed to one ear by a slight accumulation of cerumen, which will suffice to obstruct the passage of sound to the tympanum. In the other example alluded to, disease of the tympanum precedes the so-termed exostosis, and a perforation of the tympanic membrane, attended with a purulent discharge, will be present perhaps for some years before the growth of bone is discovered. It is in such a case that sometimes the exostosis, by preventing the escape of pus, becomes the indirect cause of death due to cerebral abscess. This is especially so where, in addition to the exostosis in the meatus, there is a polypus growing from the tympanic cavity. Tkeatmewt. — With this complication, or where the meatus becomes completely closed, and in these two cases alone, it occasionally becomes imperative to remove the bony growth. The position of the tumours, and their extreme hard- ness, make this no simple task ; and (except in the instance mentioned by the late Mr. Syme, when they were exceptionably friable) their re- moval has been attended with great difficulty. Up to the present time two modes of proceed- ing have been the most successful. The first of these is as follows : — ^Two needles being inserted into the base of the growth, holes having been drilled for this purpose, the continuous current derived from ten to twenty pairs of plates (Stoh- rer's battery) has been passed through them for a few minutes, and in the course of about six weeks the l)one thus destroyed has become loose, and is readily removed with forceps. The second method consists in grinding the bone away by means of a drill, now in common use with den- tists. Either proceeding is attended with so much pain that an anaesthetic is necessary. 4. Inflammation. — The external auditory meatus is subject to inflammation, diffused or circumscribed, the latter occurring in the form of small abscesses or boils. Both affections are attended by acute pain, and in each the general health of the patient has been out of order for some time previous to the local trouble. Tbeatmbnt. — Treatment in the direction of improving the general healtK; and local bleed- ing by means of leeches applied in front of the tragus, wiU often rapidly relieve the diffused form of inflammation ; but when it has con- tinued for a long period (as it not infrequently does), in addition to the soft tissues the pe- riosteum becomes affected. The passage then throughout its whole extent becomes so swelled as to nearly close the external opening, and pain is constant. The only treatment which gives complete and permanent relief under these cir- cumstances is to make two or three free incisions down to the bone, along the whole extent of the osseous part of the canal. A convenient instru- ment for^ this purpose is a small sharp-pointed curved bistoury. As to the propriety of opening 418 EAE, DISEASES OF. abscesses in thissituation there can be noquestion, for, owing to the extreme denseness of the tissues and their approximation to bone in the external, auditory canal, abscess in this part is slow in its progress and attended with very great suffering. These abscesses being especially liable to recur, a proper regimen and medicines apfiropriate to the failure in general health are required. 5. Fungi. — The external auditory meatus has been occasionally found to be the seat of two varieties of vegetable fungus, namely, Aspergillus fiams and nigricans. The symptoms which they have given rise to have been great irri- tation, and a slight discharge. They have been readily destroyed by syringing, and the loc^ application of spirits of wine, 6. Polypus of the ear is usually preceded ]3y inflanunation in the tympanic aivity and perfo- ration of the membrane ; and is considered along with diseases of the middle ear. 7. Heamatoma Auris. See Hjematoma Arius, II. Middle Ear. — All affections of the mid- dle ear originate in some part of that tract of mucous membrane which, commencing where the Eustachian tube opens into the pharynx, forms the lining of this tube, and of the cavity of the tympanum, finally becoming the inner- most layer of the tympanic membrane. To the character of this tissue is due the term catarrh, which, in its two forms of purulent and non- pilrulent, is used in describing any deviation from health which, directly or indirectly, is the cause of pathological change in the Eustachian tube or tympanum. * 1. Obstruotiou of the Eustachian Tube. — One of the most frequent conditions under which tjie Eustachian tubes become the seat of ob- steuction is that met with in children or young persons. The subjects of this affection pre^sent a very characteristic aspect. They breathe aimost entirely through the mouth, which, sleeping or waking, is kept partially open ; their tonsils are of ten, enlarged, and they snore Ipudly (Juring sleep. The mucous membrane of the nares and pharynx is swollen, and secretes in excess ; owing to this tumid state of the fauces the passages to the Eustachian tubes in this situation do not admit of the constant necessary supply of air to the tympana. The air in these cavities undergoes partial absorption, and thus becomes more rare than that external to the tympanic membrane ; the density of the outer air remaining the same, the equilibrium from pressure is destroyed ; the membrane, conse- quently, is retracted, the chain of ossicles are pressed inwards, and thus the conduction of sound becomes interfered with — in short, the patient is more or less deaf. In these cases inspection of the tympanic membrane at once reveals the state of a£6iirs. As the cavity of the tympanum is not involved in the catarrhal change, its translucenoy and lustre are not impaired ; the handle of the malleus is tilted inwards, the head of this bone is unusually prominent, and there is a distinct fold crossing the upper part of the posterior section of the membrane. Where the obstruction has lasted, for a long period, the membrane will appear to be almost fallen in upon the walls of the tympanum, and the pro- montory and incus may be distinguished. If under these conditions the tympanum be in- flated on Politzer's plan,' an instant return to good hearing follows, but in the course of a few days the improved hearing partially dies away, leaving the patient, however, in, some degree better than before the operation. Treatmbkt. — ^This should be twofold.. In the first place the, tympanum should be regularly inflated, and this may be practised at first every three or four days, and gradually at longer inter- vals. Secondly, astringent applications should be applied to the pharynx. Of these applications one of the best is a solution of perchloride of iron, 2 drachms to 1 ounce of water, and it should be used daily by means of a curved camel's-hair throat-brush. When the nares are much ob- structed, great benefit will follow the use of sa- line solutions through the nasal douche, or they may be insufflated, that is, drawn up through the patient's nose into the pharynx and then spat out. If the tonsils are so much enlarged as to in- terfere with the respiration, it will be necessary to remove them ; but the reason for this pro- ceeding is not that they press upon the opening of the Eustachian tube, but because their pie; sence keeps up the unhealthy condition of the pharynx. Under this routine of treatment the patients completely recover their hearing ; the space of time during which it is, necessary to continue treatment varying according to the obstinacy which each case manifests. Obstruction of the Eustachian tubes in advlU presents certain well-marked differences from the affection as it prevails in children. An ordinary cold is the beginning of the trouble. It is more usual to find one instead of both tubes, oh- structed, and more often than not the tympaniii cavity is involved in the catarrh. Where this is not the case — and it will be evident from the retained lustre and transparency of the mem- brane — the same principles of treatment as are pursued in the case of children will hold good, except in so far that the affection in grown-up persons is less persistent after the tube has been once artificially opened ; and that, to effect this, Politzer's method is sometimes not sufficient, or, even if so, not as efScacious as the Eustachian catheter. It must also be borne in mind that in the treatment of cases in which one ear is healthy, by means of the catheter the affected ear exclusively may be subjected to the air- douche, whilst with Politzer's niethod it is im- possible to avoid forcing a stream of air into the healthy tympanum, and this is not always an advis.i.ble proceeding. The Euatachiari Catheter.— "^e following. )» the mode of using the Eustachian catheter:— ' Place the patient in a chair, and let him lean baok; steady his head vrith the left hand firmly fixed on the top of it; hold the catheter lightly in the right hand, with the curve downwards ■ This method of inflating the miSdle ear (now in m* general use) consists in passing a stream of air from an india-rubber bag tbrougb one nostril whilst the patient swallows some water. Tbe operator at the same time closes one nostril with the forefinger of the left hand. «iia completes the closure of the other with the thumb, ii"' mouth must be kept firmly shut. RA.R, DISEASES OF. 419 and pass it quickly in this position through the inferior meatus of the nose to the posterior wall of the pharynx. When this is felt, -withdraw the catheter about half an inch, and tilt the point of the curved end rather upwards, and to the left or right, according to the side which is being operated upon. Now hold the ca'heter and end of the patient's nose steadily between the thumb and the first two fingers of the left hand. All this time the ear of the patient and that of the surgeon are connected with the otoscope. The point of the catheter is now supposed to be in the pharyngeal orifice of the Eustachian tube, but the only certain sign of this being the case is that when air is forced into the catheter it will be heard through the otoscope to impinge upon the tympanic membrane when a stream of air is passed down the catheter.' The catheter may be made of silver or of vulcanite, but, of whatever material, it must be inflexible whilst being used. Beyond this, suffice it to say here that in practised hands its em- ployment is invaluable, and indispensable in the treatment of most affections of the middle ear, not only in overcoming obstruction of the Eusta- chian tube, but also as a means by which injec- tion of fluids may be applied to the cavity of the tympanum. In making use of the air-douche an indiarubber bag fitted to the catheter should be employed, and in using injections to the tym- panum a similar arrangement is necessary. 2. Catarrhal Inflammation of the Tym- panum. — When the tympanic cavity has be- come involved in the catarrhal state, or when the affection, instead of proceeding up the Eustachian tubes, begins in the tympanum, as it frequently does, those chanijes have commenced which, of all others, form ihe most fre>iaeut impediments to the conduction of sound — in other words, which make the subjects in which they are found more or less deaf; and it may be broadly stated that the extent to which this affection is reme- diable depends directly upon the time at which the patients suffering from it apply for treat- ment. In the early stages, the obstruction to the passage of sound through the tympanum is solely due to the effusion of mucus in this situ- ation, and this is easily demonstrated by the moist gurgling sound which inflation of the tympanum produces, as may be heard upon con- necting the ears of tlie patient and surgeon by means of a piece of indiarubber tubing.' After- wards comes what may be termed the dry stage, i.e. when the fluid portion of the mucus has suf- fered absorption, and when any of the products of inflammation may hare become more or less organised, or at least in a condition which, if not interfered with, suffers no further change. The morbid conditions which result from non-puru- lent catarrh of the tympanum are twofold. Eirst, those which affect the tympanic membrane, and are, therefore, demonstrable during life ; secondly, those which are met with after death in the tym- panic cavity. The first of these include changes in curvature, in colour, and in consistence. The slighter changes in curvature have been * This tublQg should always be nsed, whether air or fluids lire being injected through thoEustachiantnbe, for upon tile BouQtiB thus heai-d, as well as on the patient's own perception, the answer to the question whether the iufliiLioD is complete depends. noticed in speaking of obstrnetion of the Eusta- chian tube, which condition is necessarily more or less present m all cases where the tympanum has been the seat of catarrh, and these changes are met with indefinitely increased until the state of complete collapse is reached. In this condition the membrane has the appear- ance of being in close apposition to the walls of the tympanum, and lapped round the ossicles, so ijiat the forms of the malleus, incus, and some- times the stapes are distinctly traceable. In so extreme an example, the membrane is generally bound down to the tympanic wall by adhesions. The first change which the mem- brane exhibits is a loss of its lustre and trans- parency ; it becomes opaque. Further altera- tions in colour, in cases of long standing, consist in the formation of patches of brown, yellow (colour of parchment), and white. Variations in consistency will include thickening throughout the membrane, or in parts of it, especially in the cases of dense chalk deposits (phosphate of lime) ; and thinning in places, so observable sometimes that inflation will induce bladder- likeprotrnsions, which, as inflation is suspended, fall back again : changes in all these respects completely meta- morphosing the appearance of the membrane, -ifter death, within the tympanum may be found collections of dried mucus around the ossicles ; thickening of the lining membrane; bands of adhesion in all directions ; and anchylosis of the ossicles to each other, as well as between the stapes and fenestra ovalis. As additional evidence during life of obstruc- tion in the tympanum, it may be mentioned that sounds from a vibrating tuning-fork placed on the vertex are intensified wheti such obstruction exists, and the nerve remains unimpaired : this test is especially valuable where one ear is healthy, inasmuch as the sound will be heard exclusively on the deaf side, this being due to the fact tliat vibrations of sound thus conveyed to the auditory nerve, on their passage outwards through the tympanum, meet with the obstruc- tion in this position, and are reflected on to the labyrinth. The appearances above described, together with the history of the case, serve SufiSciently to distinguish affections of the con- ducting from those of the nervous apparatus, and the sounds which are produced upon inflation of the tympanum, whether of a moist or dry character, give evidence as to whether the mucus in the cavity of the tympanum is in a more or less fluid state, or has reached the dry stage where the fluid part of the secretion has become absorbed, the more solid portion remaining. In the first of these conditions, the inflation at once increases the hearing power ; in the second, it. produces no change in the hearing. An indica- tion in this direction is a most useful guide in respect of treatment, for whatever differences in opinion may exist as to details in relation to this subject, experience . has amply shown that the injection of fluids into the tympanum is for the majority of cases the treatment of all others the most successful, and, speaking generally, it may be said that when the sounds which accompany inflation of the tympanum are of a moist charac- ter (showing that undue secretion from the mucus membrane is going on), astringents, such as sul- 420 EAE, DISEASES OF. phateof zinc, 1 to 2 grains to the ounce ofluke- ■warm water, will be found most efficacious ; and that when the dry stage has been arriTed at, alkaline solutions — bicarbonate of soda or jjotash, 6 grains to the ounce, or still better an injection containing hydrochlorate of ammonia, 5 grains to the ounce— should be substituted. Injecting the Ti/mpaimm.— -There are three modes of injecting the tympanum, and their order of efficiency stands as follows : — Firstly, when the Eustachian catheter has been placed in position, a few drops of the injection are introduced into it from a small glass syringe, and forced into the tympanum by means of an indiarubber bag, the nozzle of. which is made to fit the open end of the catheter. Secondly, a few drops are placed in the inferior naris, on the same side as the ear under treatment, and injected in front of a stream of air blown to the tympanum on Politzers plan, the patient's head being inclined to the side to be acted upon. Thirdly, the fluid being arranged in precisely the same way, the patient forces it up the Eustachian tube by attempting to blow through the nostrils, whilst the mouth and nose are closed. , The injection may with benefit generally be repeated every ot;her day for from two to four weeks, but for this no rule can be laid down which would apply in every case. Such is. the briefest outline of the treatment under which these cases recover in greater or less degree. The degree of improvement varies within wide limits, but the greater benefits may always unhesitatingly be predicted during the moist stage of the catarrh. Indeed, the necessity for early treatment is abundantly shown, in the instance of catarrhal affection of the middle ear, by the extremely satisfactory termination of cases treated early in the disease, and the slight relief which but too often follows when the affec- tion has been allowed to proceed for years im- checked. In such cases as the latter, the fact that considerable quantities of inspissated mucus have been found in the tympanic cavities first suggested the operation of making an incision into the tympanic membrane, and attempting the removal of mucus through the incision by passing a stream of air ' through the tympanum. This proceeding, with certain modifications afterwards introduced, is no doubt very useful in cases favourable for its employment, but it should be reserved for those which have defied the less severe means, and where there is unmistakable evidence of an obstruction to the passage of sound through the tympanum. Experiments with the tuning fork, already referred to, give valuable evidence in this direction ; but for a detailed account of this method of treatment, introduced some years ago by Mr. Hinton, the reader is referred to Questions of Aural, Sur- gery. Suffice it to say here that an incision about one-eighth of an inch in length is made in the posterior section of the membrane with a cataract-needle, and this is followed by passing a stream of fluid (a weak solution of soda) through the tympanum and Eustachian tube by means of a syringe made to fit the external meatus. In appropriate cases it is often undoubtedly of very great service, and is neither a dangerous nor a harmfiil proceeding so long as there Is no nervous eomplication ; where, however, this is present surgical interference has at times proved most disastrous. Another operation, perforaned by Dr. Webor Leil of Berlin, consists in the division of the tensor tympani muscle, but up to the present time the results at the hands of others do not warrant iti as a recognised operation for the re- i lief of conditions inducing deafness. I 3. Purulent Catarrh of the Tympanum.— . Perforation. — The form of tympanitis in which the effused products become purulent, is an acute and generally an extremely painful affection. Usually the pus rapidly makes its escape from ' the tympanum into the external meatus, by a process of ulceration throughthe tympanic mem brane, leaving as its result a perforation of this structure. In quite the early stage the affection may often be cut short by the free applieation of leeches i n front of the tragus, followed by foment- ations, but more often than not the membrane has given way before the patient comes under observation. Even then, if the tympanic cavity be emptied of the pus by the free use of Polit- zers inflation and repeated syringing, the open- ing will often close, and leave very little, indeed sometimes hardly any appreciable deafness. If, however, a purulent discharge through the open- ing be allowed to go on unheeded for any lengtll. of time, it is the exception for the perforation to heal. This condition is constantly seen after scarlet fever, measles, or any of the exanthemata. A perforation of the tympanic membrane pre- sents an infinite variety of aspects, from a small pin-hole to nearly complete loss of the membrane, but there will always be a slighti remainiig external rim of membrane. This latter ia perhaps the most frequent of all forms of per foration, and especially when the ulceration dates from an attack of scarlet fever. Although the handle of the malleus occasionally remains, it more usually comes away in these and other cases where the loss of tissue is very extensive. The head of this bone, however, may altraya be distinguished, unless there has been, complete disorganisation of the tympanic cavity. Among other forms of perforation commonly met with may be mentioned those in which the anterior or posterior half of the membrane is left, and is bounded internally by the handle of the malleus ; tihe so-called rmiform perforation, where the lower part of the membrane is lost and the umbo of the malleus indicates the position of the hilus of the kidney:; and the small,: smootii- edged circular perforation which is common aliie to all parts of the membrane. Occasionally, though not very often, the tympanic membrane is the seat of a double perforation. Similar variations in hearing accompany this condition, between slight deafness and total loss of hearing power. The size of> the perforation! affords no guide in this respect, extreme loss of hearing bwng met with when the perforation, is very small,; and very slight deafness where the loss of tissue has been most extensive, so that it may be unhesitatingly stated.that the loss of the mem- brane is but in a very small degree the.causeof the deafness in the.se cases, the disorganisation in the tympanic cavity mainly accounting for this. Such disorganisation ie at times so com- plete (especially after scarlet fever) as to indude the loss of all the ossicles, total deafness, and paralysis of the muscles supplied by the portio dura. A very small perforation in the anterior and siiperior part of the membrane may from its posiflon escape notice, but the diagnosis can be always verified by the facility with which air maybe made to pass through the opening, or the reverse, provided that the communication between the Eustachian tube and the tympanum is not closed by 6icafcricial tissue — a very rare condition when so little of the membrane has suffered ulceration. Tkeatmbnt. — The treatment of purulent tym- panitis and perforation will include assiduous cleanliness ; keeping the Eustachian tube free from obstruction ; and the use of astringent injections. When the exposed surface of the tympanum is covered, as it sometimes is, with exuberant granulations, much benefit will be derived from the application of solid nitrate of silver to the granular surface. Care being taken not to touch any other part. As the condition of the ear improves under these measures, so will the hearing power vastly in- crease when it has not been completely lost;' but there Still remains the ofttimes invaluable appli- cation of what is spoken of as the artificial mem- brane. Of all kinds, the best undoubtedly is the flattened pad of moistened cotton-wool, applied by the patient, every morning, with a pair of forceps constructed for the purpose. Until this be tried in each case it is impossible to say ■whether it will do good; but when it is useful — as it is in a large number of cases — by its help the patient will recover very good hearing, and this even when the perforation has existed for a period of many years. That its effects de- pend upon the support which It gives to the ossicles, thus re-establishing the normal pressure of the stapes upon the fenestra ovalis, has been unquestionably demonstrated. 4. Polypus. — One of the most frequent com- plications in cases of perforation of the tympanic membrane is polypus, a term employed to desig- nate a fleshy tumour in the ear. Although' polypi are occasionally present in the meatus indepen- dently of perforation, the most usual situation from which they arise is the lining membrane of the tympanum. Sometimes the exact point of origin is the edge of a perforation, and still more "rarely the sides of the meatus. In size these growths vary from a small protrusion through a perforation, to a tumour which entifely fills the meatus and projects externallyfrom the ear. In this latter instance the growth presents a very dis- tinctive appearance, not unlike a raspberry. Sec- tions of aural polypi hardened in chr,^mle acid with few exceptions show the structureto be fibro- cellular, the fibrous element preponderating over the cellular in proportion to the age of the tumour. Treatment. — In all cases polypi should be re- moved, and the best instruments for this purpose are the rectangular ring polypus forceps, or. in the case of a large growth, a Wilde's snare. Owing to thei r remarkable tendency to recur, removal is only the preliminary step in treatment. The prin- cipal part of this consists in tbeir complete eradi- saiion by caustics. Of these the most efficacious ami eonveniect is ehlor-acetic acid, and later in EAR, BISEASES OF. 421 the treatment nitrate of silver. The acid may bo applied on a very small camel's-hair brush, or on the point of a probe defended by a small twist of cotton wool, and a convenient form of nitrate of silver is a bulb of the melted salt fused on to a probe or platinum wire; The caustic should be applied daily for some time after the polypus has been removed, and then less frequently. The treatment should also include the same scrupulous cleanliness and application of astringents, so de- sirable in the case of perforations. It is simply to the want of attention to details that failure in the treatment of aural polypus may be ascribed. Complications op Tympanic Disease. — o. Facial Paralysis. — This is due to infiammation ai^jund the portio dura in its passage through the aqueduct of Fallopius. When suppuration in the tympanic cavity, with caries of the bony canal, precedes or accompanies the loss of function in the nerve, recovery is hopeless ; but when the paralysis follows a subacute catarrh of the tym- panum, not ending in a perforation, as is some- times the case, the paralysis in time disappears no less certainly than when it is dependent upon an affection of the nerve at a point after its exit from the temporal bone. b. Pyes that accompany the metamorphoses cannot be given in this place. Practically, the term echino- coccus has at length come to be employed in snch a restricted sense as to refer only to the Bcoliccs, or heads of the future Taeniae, which are normally developed from the granular layer or internal membrane of the hydatid. Different opinions exist respecting the precise structural aoanges involved in their formation, but what is ulroady known and accepted by helminthologists ECSTASY. 423 is the result chiefly of the labours of Leuckart, Naunyn, Kasmussen, Wilson, and Huxley. The clinical and hygienic bearings of this subject in relation to the so-called echinococius-disease will be discussed elsewhere. See Hydatids. T. S. COBBOID. BOHINORHYITCHUS (^X'""*. " se-a-ur- chin, and ^iyxis, a beak). — A genus of thorn- headed worms, belonging to the order Aoantho- oephala. Until the year 18o7 there does no» appear to have been a well-authenticated instance of the occurrence of this form of entozoon in the human body. In that year a young example (£. hominis, Lambl), was found, post mortem, in the small intestine of a boy, nine years of ago, who died of leukaemia {Prager Vierteljahrsohnft, 18ft9.) This specimen measured less than a quarter of an inch in length. It has been sup- posed that the parasite was an immature example of Ech. ffigas, but this view has been disproved by Leuckart. Whether it be a new and alto- gether distinct species remains uncertain. The more recent instance alleged by Welch cannot be accepted as genuine, but must be referred to Pentasioma. T. S. Cobboid. ECLAMPSIA (.'KXtfjuiTB, I flash, I explode)^ — This term is now used as a synonym for con- vulsions, whatever may be their cause. See Convulsions. EOPHTJIA (4K,ont of, and 0i?Att«, a swelling): A growth from the integument. The term was em- ployed by Mason Good as a designation for warta and corns, but is at present almost obsolete. ECSTASY (4il I bubble up).— Sraos:; Fr. tczema ; Ger. Ecsem. Definition and Geneeai, EEMAEKs.^^Eczema is an inflammation of the skin, remarkable for a multiple series of pathological symptoms, and for extremes in degree of development and dura- tion. It may be taken asthe type of inflamma- tion of the integument, and as an illustration of the varied patliological manifestations of the skin. As in other organs, the inflammation may be acute or chronic, may vary in severity and extent, and may occur at every period of life; but the special position and functions of the skin render the progress of eczema always uncer- tain and slow. .SOTiOLoay. — The proximate cause of eczema is hypersemia. Every exciting cause giving rise to hypersemia is capable of producing eczema, and if the tissue of the skin be weak will necessarily be the occasion of chat aifection. It is in this way that local irritants act on a susceptible skin, so as to produce eczema; such, for example, as heat and moisture, friction, mechanical and chemical stimulants, and ob- structed venous circulation. It is in tliis way that a poultice, a water-dressing, a stimulating lotion, or the action of the sun or of a pungent atmosphere, may be the local cause of eczema. Constitutionally, disturbed nervous function, however induced, by producing disturbance of the circulation and nutrition of the skin, ie among the commonest of the causes of eczema. The starting point may be malassimilation occurring at any period of life ; malassimilation will act as a disturber of nutrition and circula- tion of the skin, and those pathological processes known as eczema will be the result. In this manner we may trace back the cause to dis- ordered digestion, painful dentition, painful menstruation, pregnancy and parturition, or nervous shock ; and we are led to the conclusion that feeble digestion, assimilation, and nutrition constitute >« predisposing cause of general and cutaneous debility, which only requires the interposition of an exciting cause to become an eczema. That eczema is powerfully under the influence of the nervous system is shown by the sudden and sometimes periodical exacerbations of its symptoms, and their subsidence under the influence of agents which soothe and tranquillise the nerves. In the simplest form of expression eczema may be said to be a general as well as a local debility, and to be induced and kept up br ECZEMA. 42d every cause which tends to lower the life-force of the organism. Eczema is specific neither in its nature nor in its cause. Every cause of irritation acting on a frame and on a tissue enfeebled by disordered function is capable of becoming a cause of this affection. It is hereditary only in the sense of the transmission of Uiitural tendencies from parent to offspring, and not by virtue of any special virus or causa morbi ; and for a similar reason it is non-contagious. Nurses are oceii- sionally affected with eczema from contact with the acrid secretions poured out by the inflamed skin, but the same result would follow in an equal degree from contact under similar circum- stances with any other kind of irritant fluid, the two essential factors of eczema being a sus- ceptible skin, natural or artificial, and the presence of an irritant. The warmth, the moisture, and the stimulation of the wash-tub are as active a cause of eczema to a sensitive skin as the most profuse contact with eczematous discharge. And there is no more energetic generator of eczema than the sun's rays when operating on the enfeebled integument of the victims of a city life. Symptoms andVabibtibs.— The objective signs of eczema are — redness, slight swelling, papula- tion, vesiculatlon, exudation, incrustation, des- quamation, thickening,: hardening, fission or chap- ping ; and the subjective sensations, burning heat, Itching, and pain. The whole of these symptoms are not necessarily present at the same time, but they may all be in existence at once on different parts , of the same person, and their separate preponderance is marked by distin- guishing names, constituting the so-called va- lieties of Eczema. Thus, for example, when the prevailing symptom is redness, the case is one of E. erythematosum, and may subside with simple desquamation. When the hyperemia causes congestion of the follicles and their up rising in tiie form of pimples, the Ciise is termed E. papulosum. With the moderate swelling or cedema which always characterises eczema re- sulting from serous effusion, there is commonly exudation beneath the horny cuticle, giving rise to small vesicles, or E. vesieulosum, the typical eczema of Willan ; and in a pyogenic consti- tution these vesicles may be converted into pustules, constituting E. pmttdasum or impetigi- nosum. When the exudation from the suface is so excessive as to sweep away the cuticle completely, and pour forth from the inflamed skin like a veritable catarrh, ■ the i form is termed E. iaharosum seu madidansf and, from the depth of colour of the vascular base which supplies the exudation, E. rutmim. When the exuded secretion is dry on the inflamed surfaco in the form of crusts, the case is one of E. crus- taceum, and is well Illustrated by the crusia laotea of children. When, in consequence of thickening of the affected integument conse- quent on interstitial exudation, the cuticle is produced in excessive qusintity, and continues to desquamate, the eczema is termed squamosum, and is the psoriasis of Willan and Bateman. In a more advanced degree of thickening, accom- panied with induration, and in chronic stages of the disease, the skin is apt to crack and break. constituting E.fissum,^9 cracks and chaps being termed rhagades. Such a form is not uncommon in the palm of the hand, and: constitutes one of the varieties ot psoriasis palmaris. When, from any cause, a state of permanent bypersemia is main- tained in a part, such as the lovrer extremities, where it is likewise associated with obstructed venous circulation, the whole of the fibrous and epidermic tissues areapt to become hypertrophied, giving rise to E. hypertrophicnm. Besides these, the varieties of eczema due to the predominance of a particular symptom, we recognise dry eczema or . E. siconm, and moist eczema or E. hmrmdam, together with other VHrie- tiescousequent on locality, such as the scalp, the face, the flexures of the joints, the perineum, and the palms of the hands. We also distinguish, aS' dependent on severity and duration, acute and chronic eczema, and on period of life, E. h\fantiU. Eczema must be eonsiJered as one of the most pruriginous of the affections of the skin ; hence its Greek names psora and psoriasis, the former being applied, to. its more acute, and the latter to its chronic form. Itching is most severe in the dry forms of the disease, such as the< erythematous, the papulous, and the desquamat- ing kinds, and is relieved by the exudative process, whether occurring normally or produced artificially by the action of the nails or envelop- ment. In the moist forms the suffering assumes the character of pain, tingling, shooting, and aching, the pain being sometimes so severe as to be suggestive of the term E, neurosum. Eczema- being, an inflammation of the surface- membrane of the exterior of the body, is not unfrequently associated with a similar inflam- mation of the mucous membrane of the air- passages of the lungs, givini; rise to bronchitis ; hence the complication of eczema infantile with bronchitis is fa;r from uncommon, and in that respect is frequently derivative, a sudden increase of the cutaneous inflammation relieving the mucous membrane, and vice versd; and this association of bronchitis and eczema is sometimes maintained during the whole lifetime of the individuaU Sometimes the eczematous bron- chitis subsides into a chronic asthma, and some- times eczema alternates with hay-asthma. Not untrequently eczema alternates with gout, rheu- matism, or neuralgia, acting as a substitute for those affections and suggesting the commonly received opinion that eczema is a consequence of the.gouty diathesis. Another and a common complication of eczema are boils; and, in weakly constitutions lymphadenomatoua tumours are met with in the axillse^ and sometimes in the eczematous portions of the skin. The complica- tion of eczema with haemorrhoids iind varicose veins of the lower limbs is a well-recognised fflct; in the latter instance the riilated and obstructed veins being not only the exciting cause of the eczema, but leading to hypertrophous enlargement of the int^gumentand cellular struc- tures of the limb — to a state that may fairly be compared with elephantiasis Arabum. COUBSE, TB8MIN.iTI0NS, AND PeOGNOSIS.— The prognosis of eczema will be maiulv in- fluenced by the cause of the disease and the constitution of the patient; and, although con- stantly teazing and generally tedious, it has a 42S ECZEMA. natural tendency to cure, and very rarely imperils life. It is chiefly obnoxious tlirough its itching, which is sometimeB so great as to produce violent excitement of the nervous system ; and prolonged nervous irritation in- creases the exhaustion of the sufferer. Where the health of the patient is in other respects fairly good the prognosis will be favourable ; but where exhaustion of power prevails, where assi- milation is seriously disturbed, and where much irritability of the nervous system exists, the prngno.sis must be correspondingly unfavour- able. Thus eczema infantile, even when exten- sive, is easy of core if the constitution of the child be moderately good; the same may 1* said of the eczema which depends on vaccina- tion, dentition, and growth. The eczema of puerperal patients yields without difficulty to a tonic and nutritive regimen. The eczema which is substitutive of dyspepsia, gout, rheu- matism, or neuralgia, is especially influenced by the vitality of the constitution, and so also is that which is due to exhausted nerve-power. The neglected eczema of infancy and childhood may be prolonged for a lifetime and eczema is not unfrequently one of the indications of broken health, which may alternate with other manifes- tations of disorder of internal organs, or may be associated with or follow disease of the kidneys, and so prove fatal. Eczema must, therefore, be regarded as a subjective rather than an objective disease, and, although troublesome and tedious, is generally curable. It may annoy the patient for many months or years, recurring with fresh force from time to time, changing with the seasons, and as a complication of other diseases, contributing secondarily to the destruction of life. Tkkatment. — The treatment of eczema must be constitutional as well as local ; in a very few instances of chronic eczema, when all participa- tion with the original cause has ceased, local treatment alone may be sufficient, Vut such cases are exceptional. Constitutionally it will be needful to promote and regulate the functions of digestion and assimilation, and restore the powers of the system ; but as eczema always implies a want of vital power, a conservative treatment must be maintained throughout. Our best regu- lators of the digestive functions are saline pur- gatives with bitter inAisions, quinine and iron ; sometimes nitro-muriatic acid with a bitter in- fusion, and a mild aperient pill. When these have effected their purpose, we may have re- course to more decided tonics, such as the citrate of quinine and iron, strychnine, cinchona with sulphuric acid; or when assimilative debility prevails, to the citrates of potash and ammonia. Where there is much nervous irritability the bromides of potassium and ammonium are ser- viceable; and in the gouty diathesis moderate doses of blue pill, colchicum, and diuretics. It is not until these remedies have performed their share of duty that we should call into use the valuab'o aid of arsenic, and then arsenic, as a nerve-tonic and an assimilative tonic, may be said to be specific. To effect these purposes it should be given in small doses, e.g. two to four minims of liquor arseniealis or the hydrochloric eolation, m combination with wine of iron or EGTPT, UPPER. tincture of cinchona. In some instances the pe^ chloride of mercury with bark has also proved advantageous. Alkalies, as a rule, are objection- able, and if found necessary for a while, should be discontinued as soon as they produce a de- bilitating influence on the vital powers. In some few instances, where neiTous irritability is the prevailing diathesis, arsenic may be adopted from the beginning of the treatment, and infants in general require no preparation for its use. The local treatment of eczema should be alle- viative in the acute forms and stages of the affection, and stimulant in its chronic forms; First amongst the soothing remedies is the ben> zoated oxide of zinc ointment ; whilst the stimu- lants are represented by the mercurial ointments; alkaline ointments, and tar. The oxide of ziiio ointment is especially intended to form a thin coating of protection to the inflamed skin, and therefore, where it cannot be secured by a bandage will require to be repeated several times a day ; for a like reason, and to prevent the re- moval of the artificial covering so produced, washing of the diseased skin should be carefully prohibited. In the earliest stages of the eruption great comfort may be afforded by dusting the eruption with starch powder, or starch powder with the oxide of zinc, or simply with fuller's earth ; and zinc powder suspended in lime water forms a very useful lotion for protecting the eruption from the atmosphere at all stages of its progress. This latter application is also serviceable in re- lieving the distressing pruritus which alvpajs accompanies eczema. However, the most im- portant of the remedies for the relief of itching are the preparations of tar, and especially a tar lotion composed of soft soap, tar, and alcohol/ more or less diluted, and sometimes combined with hydrocyanic acid. Where eczema is accompanied with much infil- tration and cedema of the integument, especially occurring in the extremities, a process of sweat- ing the limb by means of water-dressing and a waterproof envelope has been adopted with considerable success. And a modification of this treatment by the use of the envelope at night, and the zinc ointment during the day, may be very conveniently adopted in cases where the patient is unable to keep his bed, and is called upon to pursue his daily avocations in life during the continuance of the treatment. In very chronic cases, again, where there is considerable hardness and condensation of the skin, it may be necessary to apply a blister over the part, and afterwards dress the blistered surface with zinc ointment ; or, a milder course consists in the application of a strong alkaline solution or soap. Ebasmus Wilsok. ECZEMA Marginatum. See Turn. EFFUSIOIT (e, out, nni /undo, I pour).- The escape of a. fluid from its natural channel or cavity into the substance pf organs or the cellvdar tissue, or from free surfaces. As ex- amples, may be mentioned dropsy m its vanous forms, and effusions resulting from inflamma- tion. EOYPT, TTPPER. — A very dry, im-a, EUYPT, UPPER, •winter-climate. Mean winter temperature, 62°. Season, October to March. See Climatb, Treat- ment of Disease by. BLBOTKICITY.— The purposes for -which electricity is employed in medicine are various. It is used as a stimulant to excite muscular and nervous tissue which is the seat of paralysis or pain, and as a stimulant to the tissues generally ; its chemical action may be employed for dis- solving tissues and coagulating blood -vfithin aneurismal sacs ; and its thermal effects are employed in surgery for heating cauteries. Electricity is used in its three forms of (1) Franklimc, Static, or Frictioml electricity; (2) Famdism (i.e. electricity generated by induction, whether voltaic or magnetic); and (8) Galvanism or Voltaism, which owes its existence to chemical action. Apparatus. — FranUmo electricity, which is generated by the friction of glass discs or cylin- ders, and which was formerly much in vogiie, has now become nearly obsolete in therapeutics, and need not detain us in an article like the present. Faradic batteries should consist of (1) a coil uf insulated copper wire, the ends of which are in connection with the plates of a gal- vanic cell. This is called the primary coH, and contains a bundle of soft iron wire in its interior. 2. A second coil of insulated copper wire made of finer wire and containing a greater number of spirals than the primary, which is made to slide over the primary ; this is called the secondary coil. 3. An interrupter, capable of interrupting the current automatically and with great rapidity by means of the constantly recurring magnetic action of the bundle of iron wires in the interior of the primary coil. These batteries should have means of graduating the intensity of the current of either coil, and of including the patient in the circuit of either coil without altering the connections of the conduct- ing wires. Sometimes the galvanic element is replaced by a large magnet, as in the well-known rotating magneto-induetion apparatus. Galvanic batteries when used for therapeutic or electrolytic purposes should be' composed of (1) alarge number of small cells of low electro- motive force, and as constant in their action as possible. The cells known as the ' Leolanche ' are the best. (2) Means of including in the circuit any number of cells at will, so that there- by the intensity of the current may be regulated. (S) Means of opening or dosing the circuit at will and of reversing the direction of the current without altering the position of the current- carriers (rheophores) on the patient's body. This is effected by means of a simple contrivance known as a key and commutator. Batteries which are required for heating wires and cauteries must be composed of cells of high electromotive force and as large as is practically possible. The number of cells or elements is of less importance than their size. It is not unusual to have, for this purpose, Groves' or Bunsen's cells capable of containing a pint of liquid each. The essential and distinctive differences of the two forms of current (galvanic and faradic) ure the following : — ELECTRICITY. 427 The Galvanlo Current is (I) continuoitsly evolved (hence it is spoken of frequently as the ' continuous current ' ). (2) It flows always in the same direction, i.e. from the positive pole (which is in connection with the cupper or receiving plate) to the negative pole (which is in connection with the zinc or generating plate). This frt.et must be constantly borne in mind, because the action of the two poles is markedly different, and it has been asserted (on very doubtful evidence, however) that the direction of ' the current in the body, whether towards the nerve- centres or towards the periphery, has an im- portant effect upon the physiological and thera- peutical results. (3) It has well-marked chemical and thermal effects. This action is most marked at the negative pole, with which if a moderately intense current be used, heat, redness, inflamraa^ tion, and even sloughing of the skin may be readily produced. It is, therefore, always necessary to frequently change the position of the negative pole on the body. (4)' It has electrolytic effects. When a galvanic current is passed through a conducting compound liquid, decomposition of the liquid results, oxygen (if water only be used) and acids (if saline solutions bo used) being evolved at the positive pole, while hydrogen or alkalies, as the case may be, are evolved at the negative pole. Since the human body consists of a mass of cells which contain and are bathed in saline fluids,many of the phenomena observed on passing galvanic currents through the human body, or any part of it, are probably due to this electrolytic action. Faraday called the positive pole the anode, and the negative pole the cathode, and these terms are frequently employed. Induced Current. — With regard to the in- duced current, the following points must be re- membered. (1) It is THommtary in dwation. (2) Its direction is constantly changing, so that in using it it is less necessary to distinguish between the poles. (3) Its chemical, thermal, and electro- lytic effects are nil. (4) It has much greater 'tension' than the galvanic current, that is, it overcomes the resistance of the. body with far greater ease. (6) It causes the contraction of healthy muscle far more readily thun the galvanic current. Muscular contractions only occur at the • moment of making or breaking a current, and it is mainly to the rapid interruptions of the in- duced current that its high stimulating power is due. The current of the secondary coil has greater tension, more penetrating power, and greater stimulating power than the current of the primary coil or ' extra-current.' This is due to its being composed of finer wire and having a greater number of turns. The stimulating effects of the galvanic cur^ rent which cause muscular contraction, occur only at the moment of making or breaking the current and not during its continuance, and the stimulating effect of the two poles is different, as may be demonstrated by the ' Polar method of investigation,' instituted by Brenner, of St. Petersburg. If one rheophore be placed on an indifferent part of the body, as the back, and the other be placed over a nerve-trunk or muscle, we are able by means of the commutator and key to study the action of either pole on nen-es and muscles during the making and 428 ELECTRICITY. breaking of the current. "With weak currents it is found that contraction ensues only when the stimulating rheophoreis negative (cathode), andonly on closing the circuit. This is called Cathodal Closure Contraotion (C.C.C;). If the strength of the cnrrent he sliglitly increased -we get contraction also when the stimulating rheo- phore is positive (anode), and the circuit is opened (A.O.C.). Next follows Anodal Closure Contraction (A.;C.C.), hut Cathodal Opening Contractions (C.O.C.) never occur in healthy muscles with any currents short of those of un- bearable intensity. The galvanic current, unlike the induced cur- rent, affects the nerves of special sense. If ap- plied in the neighbourhood of the eyes, flashes of light are seen, and blindness has resulted in one case from the incautious application of strong currents to the face. The gustatory nerve is affected in a similar way, andtbe 'galvanic taste' is" perceived when the rheophores are placed on the cheek. The taste is acid with the positive, but metallic and coppery with the negative pole. If the rheophores are held to the ear rumbling noises are produced, and it is said that stimula- tion of the olfactory nerve will give rise to a peculiar smell. Onimus has pointed out a further distinction between the induced and the galvanic current. ' An induced current,' he says, ' only acts during the infinitely short time of its passage, after which everything returns to order. ... It can never be anything else but a series of slight excitements. With constant currents real ex- citement is determined only at the times of making and breaking. . . . It is during the silent period, however, that the principal action of the continuous current makes itself felt.' It is Certain that the rapid interruptions of the induced current and the strong muscular con- tractions caused thereby, are capable, if the current be moderately strong, of rapidly and completely exhausting the irritability of a muscle, and, if this fact be not constantly borne in mind, harm, instead of good will result from the application of faradism. The galvanic cur- rent, on the contrary, possesses remarkable refreshing effects, a fact which has been de- monstrated by Heidenhain on frogs, and by the writer on the human subject. It is found that a man can sustain a weight at arm's length far longer than he otherwise could, if a galvanic current be passed through the nerves of the limb. The feeling of fatigue can bo removed bv the application of the current, and the force of mus- cular contraction is increased thereby. These facts have important therapeutic bearings. Modes op Application. — To apply electricity we need to have conducting wires and rheophores or current>KMirriers attached to the battery. The best conductors are made of ordinary telegraph wire, which should be as thick as is compatible with pliability. Telegraph wire is not damaged by moisture and can be readily connected to all forms of batteries and rheophores, and is there- fore economical as well as convenient Rheo- phores vary much in design. They should all have insulating handles, and the junction between the conductor and rheophore should be about the middle of its length, so that I oth conductors may he held in one hand without risk of the metallio junctions coming in contact. The most gener- ally useful rheophore is the sponge-holder. An excellent sponge-holder, which retains the sponge with absolute firmness, has been made for the writer by Messrs. "Weiss, from a design by Kidder of New York. Rheophores should ba of different sizes, from a sponge as big as half- a-crown to the pointed extremity of an olive- shaped conductor. They should be made of metal and not carbon, because the latter is too brittle. They may be obtained in the form of discs, balls, points ; and of endless desigc for reaching particular organs and regiSns, as the eye, ear, larynx, bladder, rectum, and uterus. They are usually covered with wash-leather, and used moist. A wire brush is useful for influencing the skin. The dry hand of the operator, who allows the current to pass through his own body to that of the patient, may be used for the same purpose. It is often convenient to fix one rheophore to the patient's body, which may be accomplished by placing an ordinary sponge on the surface of the body, laying thereupon the naked end of the conducting wire, and securing the whole with one turn of a bandage. If we wish to influence the surface only, we may use one rheophore dry; but if we wish to affect deeper-lying structures we must overcome the resistance of the epidermis by thoroughly moistening it with hot salt-and- water. We may use one rheophore dry, and one moist; or wo may use as a rheophore a porcelain or 'gutta- percha vessel containing water, into which the limb is placed. There are two methods of applying electricity, known as general electrisation and localised eles- trisation. By the former method we pass the current through the entire body or great part of it ; it has been employed for many diseases, but its utility is doubtful. By the latter jaethod, which we owe to Duchenne, we seek to influence special nerves, muscles, or organs, and to limit the action of the current strictly to these parts. If we wish to influence a muscle we may do so either by applying the rheophores directly over the fibres of a muscle (both the rheophores being held in one hand and 'promenaded 'over the whole surface of the muscle). This is the direct method, and is the method advocated by Duchenne. Or, instead of trying to influencethe muscle itself, we may stimulate the nerve sup- plying it, and so cause the muscle to contract. This is the indirect method, advocated by Ziemssen. It is effected by using two rheo- phores of different sizes. A large rheophore is afBxed to an indifferent part of the body, while with a small pointed rheophore an endeavour is made to touch the exact point where the nerve we seek to influence is most superficial. Neither of these methods is to be exclusively 'adhere 1 to. Certain deep-lying muscles; such as the diaphragm and the supinator brevis, 'are only capable of indirect stimulation. It will be found also that, in certain diseased conditions, muscles will not respond to stimulation through the nerves, but only to the direct application of the current. When we wish to use the refreshing effects of the current, as in cases of paralysis ■which are on the road to recovery, or in cages of ELECTRICITY. 429 fatigtied musdes, &e.,it is advisable to combine the application of the galvanic current with a rhytlimical exercise of the affected muscles. Benediftt lays it down as a rule that the locus morbi, be it brain, spinal cord, nerve, or muscle, should always be included between the rheo- phores. Diagnostic and Theuapedtical Uses. — 1. Siagnostio Uses of Eleotrioity.— For pur- poses of diagnosis, electricity is of undoubted service, since by its means we are often enabled to distinguish between paralysis due to central lesion and paralysis due to peripheral lesion. We are accustomed to speak of a paralysis as ' cen- tral ' so long as that portion of a nerve-centre is sound from which the nerves supplying tno paralysed muscles take origin. Thus in cases of damage to one corpus striatum, the spinal ocrd and the greater part of the brain being healthy, we speak of the case as one of central paralysis. In cases, too, of paraplegia from local injury, the cord below the injury being healthy (notwith- standing that all mental control is cut off) we speak of the paralysis as central. In such cases of central paralysis we find (a) that reflex stimu- lation of the muscles is possible, (4) that the muscles undergo but little wasting, and (o) that the irritability of the muscles to faradism is scarcely diminished. We speak of paralysis as due to a peripheral lesion whenever the paralysed muscles are cut off from communication with their nerve-centres, or directly communicate with centres whose physiological activity has been destroyed by disease. In such cases we find (a) that reilex stimulation of the paralysed muscles is no longer possible, {b) that the paralysed mus- cles waste with remarkable rapidity, and («) that the irritability of the muscles to faradism is rapidly diminished, and is generally ultimately destroyed. To establish the fact of diminished irritability to faradism is generally not difficult, and in cases of paralysis affecting one side of the body only it is done by comparing the paralysed muscles with their healthy fellows. We must take care that the current does not vary in in- tensity, and that it passes through exactly similar lengths of the body for the stimulation of both sets of muscles. It will be found convenient to fasten one rheophore to the middle line of the body (a big sponge tied to the back of the neck answers well), and then when the patient's limbs are arranged exactly symmetrically, test the healthy muscles first with a small or pointed rheophqre and determine the current of least intensity which will cause contraction. Then the rheophore is to be applied to exactly the same spot on the opposite limb, and, if contraction fol- lows as readily as on the healthy side, we know that there is no diminution of irritability. If, however, contraction do not follow, we increase the strength of current, and so determine to what extent the irritability is diminished, and whether or no it is completely extinguished. We should add that in cases of peripheral paralysis the di- minution and extinction of iiritability does not supervene immediately on the occurrence of the paralysing lesion, but only after the lapse of a week or ten days. In cases of paraplegia or other eases in which paralysis affects both sides of the body it is, of course, impossible to compare a para- lysed muscle with its healthy fellow, and in such cases we can only judge of the amount of irrita- bility by experience and mental comparison with previous oases. It is found, in cases of peripheral paralysis, that after complete extinction of faradie irritability the muscles will respond to a slowly interrupted galvanic current, and that not unfrequently the irritability, of the .muscles to galvanism is greater on the paralysed than on the sound side of the body. It is said by some German writers that not merely quantitative but qualitative changes take place in the irritability of these muscles and that the Anodal Closure Con- traction (A.C.O.) soon becomes very marked, and equals or even surpasses in force the Cathodal Closure Contraction (C.C.C.) j and further that the Cathodal Opening Contraction soon becomes more marked than the Anodal Opening Contrac- tion. These reactions, which are sflpposed to de- pend upon degenerative changes in the muscle, have been spoken of as the degenerative reactions. These quantitative and qualitative changes in irritability are found (1 ) in some forms of para- plegia due to> degenerative changes in the cord ; (2) in so-called spinal paralysis both of infants and adults ; (3) in traumatic paralysis due to injury of the nerve-trunks ; (i) in rheumatic paralysis, that is, paralysis due to ' rheumatic ' thickenings of the neurilemma ; and (5) in lead- paralysis. In ordinary hemiplegia the irritability cf the muscles remains, as a rule, unchanged. In some cases, however, the irritability is increased in the early' stages ; and occasionally after the paralysis has lasted some time we find slight diminution of irritability. In the disease known as Progressive Muscular Atrophy, the irrita- bility of the wasted muscles toi fstradism remains undiminished to the end, 2. Therapeutical TTses of Electricity. — a. In Paralysis. — The treatment of paralysis by means of electricity must be coBdueted rationally and with discrimination. By means of electricity we may attempt to remove the cause of the para- lysis by influencing the nutrition of the parts where such cause is situated, by acting on the sympathetic nerve-branches supplying the blood- vessels of the part. Thus it is asserted that the absorption of a clot in the brain may be hastened, and that the nutrition of a damaged brain may be improved, by acting upon the cervical sympathetic nerve. To influence the cervical sympathetic 'We place one rheophore over the superior cervical ganglion (which may be reached by pressing in- wards behind the angle of the jaw), and the other on the back, over the first and second cervical vertebrae. The use ofsueh a proceeding is more than doubtful, and in case of any improve- ment occurring it would be impossible to know to what such improvement ought to be attributed, since the passage of a current across the upper part of the neck must influence many important nerves besides the sympathetic. On the whole, we think that galvanisation of the sympathetic is not to be advised in the early stages of paralysis. Galvanisation of the sympathetic has been employed in chronic degenerative changes in the brain or cord, but with very doubtful success. The localised application of the electric cur- t3o ELECTEICITY. rent to the paralysed muedes is of undoubted serrice, and in employing it -we should bear in mind the following rules. 1. As to the object of our treatment we should remember the words of Sir T. Watson, ' That our aim is to preserve the muscular part of the locomotive apparatus in a state of health and readiness, until perad- venture that portion of the brain from which volition proceeds having recovered its function, or the road by which, its messages travel having been repaired, the influence of the will shall again reach and reanimate the palsied limbs.' 2. Always to employ that form of current to which the muscles most readily respond. Thus if the muscles act readily to faradism, then faradism is to be used. In some cases of peri- pheral palsy we find that contraction follows only on the application of a very strong galvanic current, very slowly interrupted, and accord- ingly a slowly interrupted galvanic jurrent must be used. As me case improves we shall find that a weaker current produces similar results, and that the muscle contracts with moderately rapid interruptions. And so will improvement gradually take place in favourable cases till faradic irritability and lastly voluntary power are restored. 3. Always to employ the weakest currents which will cause muscular contraction, and never to run the risk of exhausting a muscle by causing a too prolonged contraction. Each muscle should be taken in turn, and be made to contract two or three times in succession, and having gone over the whole of the paralysed muscles seriatim the process may be repeated. An application of this kind every other day is usually sufScient. 4. If the paralysis to the will remain absolute, and if the contractility of the muscles be perfect, we do no good by per- severing with electrical treatment. This con- dition is often met with in hemiplegia. The patient is absolutely helpless on one side, although the paralysed muscles are in no degree wasted, and their irritability remains normal, 5. If the paralysis to the will remain absolute, and if the irritabilityofthe musclesbediminished, then electricity is useful, in so far as it helps to improve the nutrition of the muscles and restore their normal degree of irritability. The normal degree of 'irritability and nutrition being re- stored (the paralysis to the will remaining ab- solute) electrictil treatment may be discontinued. 6. If the irritability to both forms of current has completely disappeared, we are not justified in persevering too long, nor in holding out delusive hopes to the pH,tient. Nevertheless, treatment should not be abandoned without a patient trial. [For the treatment of special forms of paralysis by electricity, the reader is referred to the ap- propriate sections of this work.] B. In Painful Affections. — The power of elec- tri&ity to relieve pain is very great. The relief is usually temporary, but in many cases is perma- nent. Electricity may act by serving to divert the mind from troubles real or fancied, or its counter- irritating effects may serve the same purpose as other counter-irritants whose power to relieve pain is well recognised. Occasionally electricity will give relief when eveiy known remedy has failed, and in such cases we must suppose that it acts by bringing about some change in the nerves themselves by its speciBe action on ner- vous tissue. All three forms of electncity are employed for the relief of pain, but the galvanic current will be found the most generally appli- cable. Some writers insist that the anode (positive pole) shall be applied to the painful spot. Strong faradisation serves in some cases to give relief. The effects of galvanism should be tried in every case of neuralgia, but it is not capable of relieving all cases, and disappointment is not unfrequent. Where muscular movements increase the neuralgic pains, arhythmical exercise of the affected muscles should be conjoined with the galvanism. Headache of all kinds not un- frequently yields to electricity; lumbago, sciatica, and those painful muscular conditions which we call ' rheumatic,' are quickly relieved by it. Tinnitus aurium will sometimes yield to the galvanic current when all other remedies have failed. y. In Bipasmoiie Diseases. — In the ti-eatment of spasmodic diseases, electricity is of limited utility. Some forms of tremor are relieved by it. Some aggravated cases of writer's cramp have yielded to it when all other remedies have failed, and a few cases of clonic torticollis have received undoubted benefit by its judicious application. Tonic spasm of internal organs, such as the bowel and bladder, has been relieved by the galvanic current. 5. In other diseases. — In addition to the treat- ment of diseases of a purely nervous character, electricity has been employed as a remedial agent in diseases whose origin is not so obviously con- nected with the nervous system. It has relieved the paroxysms of angina pectoris, and the burn- ing pains which accompany herpes zoster. It has been employed in the treatment of many obsti- nate skin-diseases by American physicians, and Br. Cheadle has recorded a case in which the dilated vessels in a case of acne rosacea were made to contract by faradisation, Eheumatic gout is said to have been benefited by a 'central' application of galvanism (one pole to the nucha, and the other to the epigastrium). The flow of urine in diabetes has been stated to be di- minished by a similar process ; and the symptoms of exophthalmic goitre have (it is said) been diminished by galvanisation of the cervical sym- pathetic. There is in fact scarcely a disease, from epilepsy to chilblains, in which it has not been alleged that electricity has been of use. In obstetric medicine, for the arrest of post- partum haemorrhage, faradisation is now one of the recognised means to be employed ; and it has been of more doubtful service for the rectifica- tion of displacements of the uterus. Ovarian pain and tenderness have been relieved by the galvanic current, and amenorrheea has often yielded to electricity. t. Galvano-cautery and Galvano-puTietifre.— The chemical and thermal effects of galvanism are largely employed both in surgery and medi- cine. Its thermal effect has been used for the heating of cauteries; and cauteries so heated have very obvious advantages over all other forms. The chemical effect of the negative pole has been used as a caustic for the destruction of tissues, and tumours of considerable size have, it is said, been ' dispersed' by this means ELEOTBICITY. GalTano-punoture has been used in the treats ment of hydatid cysts of the liver, but it is at least doubtful whether simple puncture is not quite as sernceable. G-alvano-puncture seetrfs likely to tajce a recognised position among the means at our disposal for the treatment of aortic aneurisms. Several cases have been recorded in which improvement has followed this method of treatment, and it seems possible that the opera- tion may be accomplished without danger and almost without discomfort to the patient. The eurrent employed should be generated by a, number of small cells of low electromotive power (Smee'a cells as modified by Foveaux seem the best). Each pole should terminate in a fine steel needle, carefully insulated except at the point. Both these needles should be passed completely into the aneurismal sac, care being taken that the points of the needles are free in the sac, and that they do not touch, but are separated by an interval of an inch or inch and a half. When the current passes, the whole of its effect will be exerted on the blood within the sac ; and, owing to the insulation of the needles, the coverings of the sac will receive no damage. The effect of the current is to cause a firm coagidum to form round the positive pole, while the liberation of gas at the negative pole causes there a frothy soft coagulum. As a rule the gas generated is swept onwards by the blood-current and causes no trouble, but occasionally distension of the sac has resulted. The clot formed at the positive pole seems to act as a foreign body, and further coagulation may take place around it, until com- plete consolidation of the aneurism has resulted. It will be found that a current from ten or twelve cells can be borne for an hour or more, and that no chloroform will be needed for the operation. When the needles are withdrawn the orifices must be closed by collodion. A repetition of the operation is generally, necessary, and roay be performed at suitable intervals. G. V. POOEB. EIiEFHAKrTIASIS ABABIJM (i\4iptts, an elephant). — Synon. : Fr. Elephantiasis; Ger. EkpAantiasis. Befinition. — A non-contagious disease, cha- racterised by recurrence of febrile paroxysms, attended by inflammatioa and progressive hyper- trophy of the integument and areolar tissue, chiefly of the extremities and genital organs ; and occasionally by swelling of the lymphatic glands, enlargement and dilatation of the lymph- utics, and in some cases by the co-existence of ahyluria, and the presence in the blood of cer- tain nematode haematozoa ; together with various symptoms indicative of a morbid or depraved state of nutrition. .SmotoaT. — Elephantiasis is endemic in India, the Malayan peninsula, Chioa, Egypt, Arabia, the West Indies, and parts of America, chiefly in localities within the influence of the sea air ; and it occurs sporadically all over the globe, except- ing, perhaps, in the extreme north and south. Certain conditions of soil and climate, such as humidity, heat, malarious influences, and proxi- mity to the sea-coast, seem to be concerned in producing the diseiise and influencing its develop- ment. Bemoval from the territorial endemic area ELEPHANTIASIS. 431 checks the disease, whilst return there reproduces it. Elephantiasis affects both, sexes, and persons of all ages and conditions of life. No race is exempt, but it is much more frequent in dark than in fair races ; and more men suffer ftom it than women. It occurs at all ages, but is most common in adult and middle life, comparatively rarely beginning in young children or in the aged. Elephantiasis is doubtfufly hereditary ; but Rich- ards found that of 236 persons, 73 per cent, had one or both parents affected. Various causes are assigned for the disease. Air, water, food, and, as it is common near the sea-coast, eating fish have been frequently credited with producing it. The presence or vicinity of certain forms of vegetation, and the geological formation of the soil, have also been regarded as predisposing and determining causes. Climate and locality, com- bined with bad living, are doubtless the real predisposing causes ; and it is probable that, as Dr. T. Lewis has suggested, it may be found to be intimately associated with the presence in the blood of certain parasites. No race is exempt from the disease, but, whatever may be the ex- planation, the white suffer less than the dark races. It does occur occasionally, though very rarely, in the pure European in India, but more frequently in those of mixed descent ; it wiU generally be found that where it occurs i n persons of apparently European parentage, there is a mixture, however slight, of dark blood. Anatomical Chabaotehs. — The hypertrophy of elephantiasis in most cases appears to be simply an increase fn the natural elements of the part, the blood-vessels and lymphatics shar- ing in the growth. In other cases the lymphatics and lymph-spaces are most concerned, giving rise to a condition that has been- described as nevoid elephantiasis, in which the appearance is presented of a soft arid fluctuating swelling, which when punctured gives issue to a white or pinkish fluid, very closely resembling chyle. The lymphatic glands also share in the enlargement. la other respects the progress of this is like that of the ordinary forjn of the disease. The Filaria sanguinis-hominis is sometimes found in great numbers in the blood of persons suffering from elephantiasis. See Eilabia San- GUINIS-HoMimS. Symptoms. — The ordinary form in which ele- phantiasis presents itself is hypertrophy of the integument and areolar tissue of some part of the trunk or limbs, and notably of the legs and genital organs. The skin becomes enormously thickened by hypertrophy of all, the, fibrous ele- ments of its structure, attended by the deposit of a quantity of albuminous fluid in the cells of the areolar tissue. The papillae are prominent and much increased in size. The integument is formed into hard mas.-es or folds, with a rugose condition of the surface, not uijlike the appear- ance of an olephanlj's leg. The f^et anj toes are sometimes almost hidden, and the scrotum or labia form enormous outgrowths,' The scrotum often attains great weight, and may be aecomr panied by large hydroqeles. Scrotal tumours hijve been removed weighing upwards of .) 00 lbs. The onset of elephantiasis is frmiiently violent and attended witli great sufftjring^ There io 432 ELEPHANTIASIS AE^VBUM. high fever ; intense pain in the lumbar region, groin, spermatic cords, and testes, which become swollen; while acute hydroceles form. These symptoms are often attended with sympathetic vomiting, nausea, and rapid erythematous swell- ing of the external parts ; and, if the extremi- ties be attacked, the swelling may be tense and jainful, accompanied by much effiision into the areolar tissue. The surface of the integuments is much inflamed, and sometimes discharges a, serous ichor or chylelike fluid, according to the extent to which the lymphatics are engaged in the particular case. The great tension and swell- ing of the spermatic cords are apt to dilate the abdominal rings so widely, that after recovery the patient may suffer from hernia. In some cases of elephantiasis the integuments are also the seat of a dilated and turgid condition of the lymphatic vessels, which during the periods of vascular excitement, when the febrile attacks occur, give way and discharge a chyle- like fluid ; in other cases the Eur&,ce temporarily assumes a herpetic condition, which weeps an acrid and offensive serous exudation. Elephantiasis not unfrequently occurs without much or any obvious injury to, or disturbance of the general health during the intervals between the febrile attacks, which in some cases are few and slight. The appetite, spirits, and strength are good, the functions are all normally performed, and the only inconvenience is that due to the size and weight of the outgrowth. On the other hand, it is frequently quite the reverse; the rapidly recurring febrile attacks, pain, exhaus- tion, suffering, and visceral complications, in- duce a state of cachexia and debility sometimes so serious as to render even surgical interference impracticable. Withal, hepatic and splenic en- largements do not as a rule result from the per- sistence of the elephantoid fever alone ; though not unfrequently, as a more direct result of malarious poisoning, they seriously complicate the evils of the sufferer's condition. Albuminuria, as well as chyluria, is occasionally present. In some cases, after the outgrowth has at- tained a certain bulk, it ceases to grow altogether, or increases slowly and insidiously without febrile disturbance, and in such cases the general health remains good. But there is generally a tendency to recurrence of the fever once or twice a month, when the parts affected become tense, hot, painful, and swollen, and often discharge a serous or lymph-like fluid, which may be acrid and offensive. Some tumours, on the other hand, are very slightly, if at all so affected, and remain perfectly dry. In all cases, however, some growth goes on, and even when, as occasionally happens, fever has ceased to recur, .there may be a gradual, but slow and painless^ increase of the hypertro- phy. The greatest variety and uncertainty ob- tains in the duration and progress of the growth ; sometimes it is very rapid, at other times it is slow, with intermissions of activity and indolence of development. The disease elsewhere than in the genitals, unless it be accompanied by exhaustion and de- bility, causes no failure in flie generative powers in either sex. Women may have a tendency to miscarry when suffering from elephantiasis. CoTiESE, DuBATioN, AND Tebminatioks. — Ac- cording to Richards, the average duration of the disease, as deduced from the observation of 636 cases, was 11^ years ; and he notes that the earliest age was nine years, whilst the latest at which he observed it was eighty years. It appears from this that the disease has little influence in shortening life. Pathology. — The outgrowths in elephantiasis are the local expressions of a constitutional disease, and are not to be regarded merely from their local point of interest. They are the re- sult of certain climatic influences whose exact nature ia not at present determined ; though, considering the geographical range of the area where the disease is endemic, it seems probable that, whatever other cause may be at work, the so-called malarious influences play an important part in its production. ' The recent researches of Dr. T. Lewis into the pathology of chyluria in India, and his discovery of certain hsematozoa in the blood of those af- fected with that disease, coupled with the fact that the subjects of chyluria and hsematozoa are also frequently, if not always, affected by ele- phantiasis with its febrile paroxysms, hyper- trophied integument, and lymphatic disturbance, are very suggestive of a community of origin of these morbid conditions. Tkeatment. — Little has yet been done by con- stitutional treatment in cases of elephadtiasis, Bemedies useful during the febrile paroxysms have little power in preventing recurrence or in checking the disease. Iodine, combined with quinine, arsenic, and iron, has been found useful to a certain extent. During the febrile state salineSi diaphoretics, and such remedies as are needed during the pyrexial state of malarious fevers, are indicated. Opium may be necessaiy to relieve the intense pain which often accom- panies the onset of the stage of excitement. When the febrile stage has passed^ quinine is useful, which, if anaemia exist, should be com- bined with iron. The local application of iodine in such forms as the iodide of lead or the bin- iodide of mercury has been thought useful; but as this is generally combined with pressure in the recumbent posture, the benefit is probably due to the latter. Such measures, along with im- proved hygienic conditions, may no doubt control the progress of the disease and relieve suffering. No remedy, however, is so potent as change of climate, by removal from the endemic site of the disease. This, if effected in the earliest stages, may coinpletely arrest the disease, and perhaps even disperse any incipient structural change. This has been observed in the rare cases in which elephantiasis occurs in Europeans, who on re- turning to Europe, have after ~ time lost the disease, and almost, or entirely, any hypertrophic changes that Jnay havo occurred. Natives of India improve if they leave the endemic area during the early stages, and go and reside in other and drier localities. However, when the hypertrophy is advanced, the paroxysms of fever are still liable to recur, even when the climate is changed, though with less violence. Surgical treatment; where the hypertrophjr is advanced, is often most successful in relieving the Bttffeper, not only of the local trouble, but also of the fever. Tumours of the genital organs. ELEPHANTIASIS. iiometiines of enormous size, are now removed \ntli complete success and comparatively small mortality. Before commencing the operation, especially in the ease of a large scrotal tumour, it IS well to drain it of blood by placing the pa- tient on his back, and elevating the tumour on the abdomen for an hour or so, during which time pressure by a bandage (a modiiication of Ea- march's) may be tried, and cold (ice) may be applied. Duringthe operation the. application of a whipcord ligature drawn tightly round the neck ^ the tumour also prevents loss of blood. The removal of a scrotal tumour is effected by incisions along the course of the cords and the dorsum penis. The cords, testicles, and penis are turned out by a few touches of the knife, and then reftected and held up on the abdomen, while the mass of the tumour is rapidly' swept away by a few bold incisions in the perinseum. The numerous venous and arterial bleeding points should then be arrested and the wound dressed with oiled lint covered with antiseptic dressing. No attempt should be made to preserve flaps of integument either for the penis or testesi It is unnecessary, and almost certain to be followed by recurrence of the disease. The process of cicatrisation goes on rapidly, and in from two to four months all is closed in by cicatrical tissue, which gradually perfects ^ itself, and has no liability to become the seat of a return of the disease. If the shock be severe the patient should be left on the table until reaction has thoroughly set in. Of J93 cases of scrotal elephantiasis operated on iu the Medical College Hospital in Calcutta, 18'2 per cent, proved fatal. Joseph Faybeb. ELBTEK, in Saxony.— Alkaline sulphated waters. See Mineeal Watees. EMACIATIOU (emacio, I make lean).— Wasting or loss of flesh. The term is applied both to the process of wasting, and to the con- dition that results therefrom. See Ateopht. EMBOLISM (r^/SoW, a plug).-SYKoir. : Fr. emoolte ; Ger. JEmbalie. Definition.- The arrest in the arteries or capillaries of some solid body, which has been carried along m the course of the circulation. _ Patholoqt.- Emboli usually consist of por- tions of fibrine derived from thrombi of the veins or heart, or of vegetations detached from the cardiac valves. They may, however, be formed by fragments of tumours which have grown into the blood-vessels, or of other.foreign bodies which have obtained entrance into the circu- lation. The effects of embolism may be divided into twoclasses :--First, those which are caused by the arrest of the circulation; and secondly, those The embolus may, first, be supposed to con- sist of some indifferent substance not possessins any irritatmg qualities. The effects which maf ften be «;used by arterial embolism are mainly Jiose.— First,atransientansBmiaoftheterrito^ 28 EMBOLISM. 433 supplied by the blocked artery. This may pass away without leaving any permanent conse- quences. Secondly, necrosis of this territory. This may be either sudden, in the form of gangrene ; or more gradual, in the form of softening or wither^ in^. Thirdly, the formation of a hamorrhagio infarction, that is, congestion of the territory, fol- lowed by extravasation of blood into the tissues, and so the formation of a firm, solid patch of a dark red colour, usually of a wedge shape, with the apex towards the embolus, and the base to- wards the periphery. In very soft organs, as the brain, the extravasation may break down the tissue and cause the ordinary phenomena of an apoplectic clot. These hsemorrhagic infarctions undergo various subsequent changes. TJsjially a process of degeneration sets in ; the blood-pigmen t passes through its usual transformations, the patch changes from dark red to tawny and yellow, undergoesmolecnlardisintegration, slirinks away, and ultimately leaves adepressed fibrous patch in which the remains of the altered blood, crystals of hsematoidin, &c., may often be re- cognised. Sometimes the patch softens down into a puriform fluid, which may become sur- rounded by a fibrous capsule, and ultimately dry up, or even calcify. When recent these patches are usually surroimded by a halo of congested The cause which determines these different results of arterial embolism is, in the main, the anatomical arrangement of the blood-vessels. Supposing the embolus to be lodged in an artery which gives off anastomotic branches between the seat of the embolus and the final capillary distri- bution, the effect in most cases will be transient ansemia, the collateral channels will enlarge, and the circulation will be again restored. A throm- bus wiU form on the embolus and will extend back to the next arterial branch, and the changes described in the article on thrombosis will take place in it {see Theombosis). If the blocked artery be of large size, and supply important organs, the symptoms of temporary arrest of function of the part supplied by the artery will follow, as transient paralysis, dyspnoea, coldness of the extremities, &c., according to the artery affected. Should, however, the artery be small, and not supply im- portant organs, no symptoms whatever will be caused, and this is the case in the majority of embolisms. Supposing, however, the artery is what Cohnheim calls a terminal artery, i.e. one which gives off no anastomotic branches be- tween the embolus and the final capillary dis- tribution, and that the capillary anastomosis with other arterial territories is insufficient to supply a collateral circulation, and that the presence of valves prevents the reflux of blood into the territory from the veins, it is manifest that the embolism must completely cut off th» blood-supply, and consequently cause necrosis in some form or other of the territory.. The network of anastomosing, channels is however, so dose in most parts of the body, that m order to produce this effect it is necessary either that the mam artery of the part be obstructed, or else that there be multiple embolisms blocking un at the same time several arterial branches, and so stopping the channels of collateral circuit 481 KMBOLLSM. The mode in whieli the hiemorrhagic infarction is produced is still a Bubject of dispte. Ac- cording to Cohnheim, whose views until recently were generally accepted, the hsemorrhage is due to a reflux from the veins into the territory sup- plied hy the blocked artery. This first causes congestion, and then extravasation, in conse- quence of impairment of nutrition of the walls of the blood-vessels; for the integrity of which the circulation of the blood is essential. Accord- ing, then, to Cohnheim, in order to produce the plienomena of the hsemorrhagic infarction it is necessary that the artery be a terminal one, i.e. one which gives off no anastomotic branches for some distance before its final capillary distribu- tion, and that the veins be not furnished with valves. These conditions are met with in the spleen, the kidney, the brain, certain branches of the pulmonary artery supplying surface lobiUes, and the central artery of the retina ; and on these grounds he accounts for the fre- quent occurrence of hsemorrhagic infarctions in these organs, though there is no reason to sup- pose that, with the exception of the lungs, embo- lisms are more frequent in them than in other parts. The more recent researches of Dr. M. litten, Zdisohrift fur JcUnische Medicin, Vol. I., render, however, these views no longer tenable. He shows by experiments on the kidney, spleen, lung, &c., that if the blocked artery be a strictly terminal one, i.e. one whose area of distribu- tion has no other arterial supply, the phenomena of the haemorrhagic infarction do not occur, even though the vein have no halves ; and under other circumstances that the infarction takes place although the vein has been ligatured, hence the cause of the infarction cannot be venous reflux. Thus if both the renal artery and vein be ligatured, infarction of the kidney takes place, the kidney receiving a sufficient collateral supply of blood from other sources ; but if the capsule were first stripped off, and the kidney be left attached only by the zenal artery and vein, no infarction took place, though the vein was left pervious. Similar results were obtained in other organs ; hence it would seem evident that the congestion and infarction following embolism are produced by an afflux of arterial blood into the territory from collateral channels. Should these be numerous, and should small arteries open directly into the anaemic territory, the cir- culation will soon be restored, and no infarction will take place; should, however, the communi- cation he imperfect, and only by means of capil- laries, a congestion of the territory leading to diapedesis and infarction will result, the vis a tergo being insufBoicnt to propel the blood on- wards into the veins. He has also shown that the vessels in which the circulation has been arrested retain their integrity much longer than was supposed by Cohnheim, and that in the kidney long before the vessels suffer necrosis of the epithelium takes place, the nuclei of the cells disappear, their protoplasm coagulates, and they become con- verted into swollen hyaline masses {coagulaiion necrosis), which have a remarkable tendency to calcification. Hence the wedge-shaped white embolisms often seen in the kidney are not pro- EMETICS. duoed by decolorisation of haemorrhagie infarc- tions, but are simply the result of the necrosis of the epithelium; and the halo of injeetion which is often seen to surround them is due to inflammatory congestion caused by the presence of the necrosed patch. This explanation of the mode of production of the hsemorrbagic infarction is more closely in accord with the view originally propounded by Virchow, who regarded the haemorrhage as due to collateral fluxion. We have now to consider the effects of emboli which possess irritating or poisonous qualities such as those derived from the purifonn softening of venous thrombi in cases of septic inflamma- tion, &c. The mechanical effects will be the same as those of the previous class ; but, in addition, these emboli set up a suppurative inflammation in their vicinity, quite independent of any ob- struction of the circulation. Hence it is that we meet with pyaemic abscesses, as the result of infecting emboli, in aU parts of the body, while the effects of obstructed circulation are, for the most part, confined to certain organs. Thns the liver is very frequently the seat of embolic abscesses, while haemorrhagie infarctions do not occur there. In the lung, where in parts ter- minal arteries are found but for the most part there is free anastomosis, the two processes aio often seen side by side. The different effects of these two classes of embolism are very manifest in the capillaries. Simple emboli, of suchsmall size as to become first arrested in the capillaiies, either cause no permanent change at all, or, at most, produce a punctiform haemorrhage. Infect- ing emboli, on the other hand, give rise to the miliary- abscesses so characteristic of pyaemia. W. Caylki. EMESIS {Ifita, I vomit). — A synonym for vomiting. See VomriKO. EMETICS (E/ue'ai, I vomit).— SraOH.: Fi, Emiciques ; Ger. Breckmittei. Definition. — Agents that produce vomiting. Enumebation. — Copious draughts of Inie- warm water. Mustard, Sulphate of Zinc, Sulphate of Copper, Carbonate of Ammonia, Common Salt, Alum, Chamomile, Tartar Emetic, Ipeeacuaiiha, and Apomorphia. Action. — The act of vomiting consists in the simultaneous spasmodic contraction of the dia- phragm and abdominal muscles, and relaxation of the cardiac orifice of the stomach; so that its contents are expelled. When the diaphragm and abdominal muscles contract, but the cardiac orifice remains closed, so that the contents of the stomach cannot escape, the expulsive efforts are termed retching. The nervous centre which regulates these movements is situated in the medulla oblongata ; and it may be excited either directly by the action upon it of drugs earned to it by the blood, or reflexly by irritation of various nerves. The drugs that act directly upon it have the same action, whether they are intro- duced immediately into the circulation or ab- sorbed by the stomach. They may thus produce vomiting and evacuation of the stomach witiont being taken into the stomach at all, and on this KMETICS. account theyaro fanned aWircci emetics, although they act directly upon the Tomiting centre. Such are ipecacuanha, apomorphia, and tartar emetic. Similarly the drugs that excite it refloxly are still termed direct emetics, because they are ap- plied directly to the stomach. Such are the sul- phates of zinc, copper, and alumina ; carbonate of ammonia; salt; mustard; and chamomile, which irritate the nerves of the stomach. Tick- ling the fauces with a feather, or with the finger, also excites reflex vomiting, and may be adopted either alone, or in order to aid the action of other' emetics. The terms direct and indirect, there- fore, as applied to emetics, relate to the stomach and not to the centre for vomiting. Direct emetics, as they stimulate the nerves of the stomach only, have little action except that of simply exciting vomiting. The indirect emetics, which excite vomiting by their action on the medulla oblongata, act also on other parts of the nervous system, and cause secretion of saliva, secretion of mucus from the oesophagus, stomach, and bronchial tubes, and perspiration. They also cause much nausea, depression of the circulation, and loss of nervous and muscular power. Further, the vomiting they induce is more continuous and violent, and often expels the contents of the gall-bladder, causing part of the bile to flow into the stomach, and be thus evacuated. Uses. — Emetics are employed to remove the contents of the stomach under various circum- stances. Firstly, when the food is causing irri- tation, and not undergoing proper digestion, as, for example, in dyspepsia or sick-headache ; and in such cases large draughts of lukewarm water, of mustard and water, or of an infusion of cha- momile are usually found beneficial. Secondly, in cases of poisoning ; and here mustard, sulphate of zinc, or sulphate of copper are best, as they einpty the stomach most quickly and effectually. Thirdly, to cause the expulsion of bile from the gall-bladder, or remove bile from the body in biliousness, fevers, and ague. When the bUe- duet is stopped by a small gall-stone, the pres- sure exerted on the gall-bladder during vomit- ing has been known to cause the expulsion of the calculus. In biliousness, excess of bile is more readily removed by vomiting than by purging, as there is no opportunity for the bile to be ab- sorbed on its way from the gall-bladder to the mouth, whereas it may imdergo absorption on its passage through the intestines. It is supposed by some that various poisons circulate occasionally in the bile, such as the malarious poison which occasions ague, and possibly other septic poisons which give rise to fevers. The advantage of emetics in ague is undoubted, as it can certainly sometimes be cured by them without quinine, and_ the action of quinine is always aided by their use. They have also been recommended in the early stages of continued fevers. In such cases tartar emetic or ipecacuanha are most service- able. Fourthly, to cause expulsion from the air- passages of falsemembrane in croup or diphtheria, or of secretions in bronchitis and phthisis. For these purposes ipecacuanha is the emetic most frequently chosen, but if it does not act rapidly T croup, sulphate of zinc or sulphate of copper may be employed, and in cases of either croup or EMMENAGOGUES. 435 bronchitis where there is great depression of the circulation carbonate of ammonia may be used with advantage, as it not only causes vomiting, but at the same time stimulates circulation. T. Laudke BnuNTON. BMMBlTAa-OaiTBS (ejniuiji/o, the menses, and &yu, I move or expel). Definition. — Emmenagogues are remedial agents which stimulate or restore the normal menstrual function of the uterus, pr cause ex- pulsion of its contents. ■ Endmeeation, — Emmenagogues may bo either indirect, as Iron, Strychnia, and other tonics, Warm Hip-baths, Leeches, Mustard Stupes, Aloetic purgatives, &c. ; or direct, as Rue, Borax, Savin, Myrrh, Cantharides, Guaiaeum, Apiol, Quinine, Digitalis, and Ergot — most of wliich, when given in larger doses, produce abortion, and are called Eobolics. The most efficient means, however, of obtaining this last-named action are those of a mechanical nature, so well known to obstetricians, and directed either to the actual rapture of the membranes, or to their separation from the cervix. Action. — The indirect emmenagogues act by improving the quality of the blood, giving tone to the nervous system, or irritating adjacent parts or organs, from which a stimuiating influence is conveyed by reflex action to the womb. The direct drugs in moderate doses gently stimulate the uterus, promoting the menstrual flow, or even checking it when in excess ; but when further pushed they cause powerful con- traction of the uustriped muscular fibre, of which its walls are mainly composed. Ergot, which is the principal, and in fact almost the only really useful member of the group, ia be- lieved to act either directly on the muscular tissues themselves, or through the intermediate intervention of some central orperipheral nervous influence. Uses. — Checked or retarded menstruation fre- quently results from anaemia or general debility, and the indirect emmenagogues will under these circumstances usually effect a cure. If, however, the case prove more obstinate, a little ergot added to the iron will often restore the sus- pended function. If even this do no good, some mechanical impediment probably exists, or some altered physical condition of the womb which mere drugs cannot rectify. Ergot is fre- quently employed in cases of lingering labour from simple inertia of the uterus, but its use must bo strictly confined to those cases in which there is no marked disproportion between the maternal passages and the head of the child. Advantage is also taken of its contractile powers in the treatment of uterine haemorrhages, or for the destruction of the smaller varieties of polypi, which are so frequently contained within the womb, by cutting off their blood-supply. Finally, it may be necessary, under certain con- ditions, to induce abortion or premature labour, as when constant sickness, or albuminuria, or compression of adjoining neighbouring viscera seems to endanger the mother's life, or when pelvic distortion renders it impossible for a living child to be bom at full term. When the 436 EMMENAGOGUES. medical attendant has made up his mind that interference is necessary, he generally has re- course to one or other of the mechanical methods which are fully described in works more particu- larly devoted to ohatetrios. KOBEBT FABQUHAESON, BMOLIiIEM'TS iemollio, I soften). — ^Defi- NrrioN. — Substances that soften and relax the parts to -which they are applied. ENnMEBATioN. — The principal emollient ap- plications are ; — ^Warm water, Steam, Poultices mode of substances which retain heat and mois- ture, for example, linseed-meal, bread, bran, flour, oatmeal, and figs ; Fatty Substances, as linseed, olive, almond, and neat's-foot oil, lard, and suet ; Spermaceti, Wax ; Soap Liniment and other lini- ments ; Glycerine ; and Para£Snes, such as vase- line, unguentnm petrolei, &c. To these may be added such substances as do not properly relax the tissues, but protect the surface from irritation, such as White of Egg, Gelatine, Isinglass, Collo- dioD, and Cotton-wool. Action. — Emollients relieve the tension and pain of inflamed parts by their action both upon the blood-vessels and upon the tissues them- selves. They cause all the contractile tissues to relax and dilate, and thus, lessening pressure upon the nerves of the part, they relieve pain. They soften superficial parts by.supplying them with either fat or moisture, and by increasing the supply of blood. In this way.they prevent the skin from cracking after exposure to cold. When the cuticle is lost they form a covering, under which the skin may heal; and they pre- vent the injurious conseciuences of friction from without. Uses. — ^Fatty emollients are used to prevent the skin or mucous membranes from cracking; to prevent irritation or ulceration between parts constantly in contact, as on the limbs of children near the joints ; to prevent bod-sores ; to aid the healing of blisters ; or in skin-diseases, such as eczema. They are also used, especially in the form of linimentum calcis, as applications in bums and scalds, for which purpose such substances as cotton-wool are likewise frequently employed. Mucilaginous substances are useful when swal- lowed to relieve pain and irritation in the throat, and to lessen irritable cough ; and such substances as figs are employed to protect the intestines from injury by hard and painted substances which have been swallowed. Warmth and moisture are applied in the form of poultices to the surface in pustules, boils, carbuncles, and deep-seated in- fiammation of the limbs, and in inflammation of the internal organs {see Pouitioes). In the form of vapour they are useful in inflammation of the air-passages (see Inhaiatioits). T. Lahdeb Bkunton. EMPHYSEMA of Iiungs. See Lungs, Emphysema of. EMPHYSEMA, STTBOIJTAIJ-EOUS (^h, m, and <))B(ro, wind). — Stnon. : Fr. emphytime ; Ger. WindgeechumUt. — Subcutaneous emphysema is the distension of the spaces of the areolar tissue with air or any other gas. There is thus produced a swelling, in slight cases affecting a very limited *rea, in extreme cases extending to the subcuta- EMPHYSEMA, SUBCUTANEOUS, neous tissue of the whole body. Unless the tension is great the swelling is slightly lobulated; itig elastic, and although the finger sinks readily into it, no lasting impression is left. When the area affected is small, the gas can be driven in any direction by the pressure of the hand. On pal- pation a peculiar fine crepitation is felt, whi^ is absolutely diagnostic. On percussion there is superficial resonance, the note resembling that obtainable from a bladder loosely filled with air. Unless the gas causing the emphysema is the pre- duct of decomposition of gangrenous tissues, as in spreading gangrene, there is no redness of the skin. The swelling usually forms rapidly and may extend in a few minutes over the greater part of the body. In such eases it is mostmarked where the subcutaneous tissue is lax. In the face' the features are obliterated, and the ejes closed by the swelling of the lids. The scrotum and penis become enormously distended. Mthouosi ahd Patholoot. — Wound of the lung from a broken rib or from a stab is the most common cause of subcutaneous emphysema. If from a stab, it can only occur when the opening in the pleiira and that in the skin no longer cor- respond with each other, in consequence of an alteration in the position of the patient, or vhen the wound has been artificiallyclosed. Whenfrom wound of the lung, it may occur with or without pneumothorax. Nothing is more common than to find a limited emphysematous swelling round a fractured rib, without any signs of air in the pleural cavity. This arises either from adhesions existing between the parietal and visceral layers, or from the escape of air being very limited. In severe cases with pneumothorax the mechanism of the production of emphysemais as follows :— A wound in the lung always allows air to pass irom it readily, but from the way in whidh the soft pulmonary tissue falls togetheij no amount of force can drive air through the wound in the opposite direction. It thus acts somewhat like the valve of an air-pump. The first effect of the escape of air into flie pleural cavity is to cause collapse of the lung. As the chest expands with each inspiration air rushes from the wound in the lung into the pleural cavity : as it contracts in expiration, the air, being unable to pass back by the wound, is driven through the opening in the ■parietal pleura into the subcutaneons cellular tissue. In such cases there is graduallyincreas- ing dyspnoea, with great distension of the sub- cutaneous cellular tissue, and unless reUef is given the patient dies asphyxiated. Emphysema occasionally occurs from rupture of some of the air-vesicles during' a violent ex- piratory effort. • Walshe states that this accident has happened from ' the efforts in parturition, defsecation, raising weights, coitus, Tiolent cough- ing, paroxysms of rage, eixcessive laughter, and hysterical convulsions.' The air usuaUy escape! first into the cellular tissue between the lobules of the lung, giving rise to the condition known as interlobular emphysema. It then finds its way into the mediastinum and from thence to the root of the neck. Interlobular emphysema gives rise to intense dyspnoea, and has been known to cause sudden death. Emphjsema has also been seen as a consequence of ulceration of the trachea, and in a few veiy rare cases as the EMPHYSEMA, SUBCUTANEOUS. rcBult of ulceration proceeding from a cavity in the lung through the adherent pleura and inter- coBtal musdes to the subcutaneous cellular tissue. Localised emphysema of the face is a symptom of fractures implicating the antrum. Emphysema of the flanlcB is an occasional symp- tom of rupture of the third part of the duodenum, behind the peritoneum, and of perforation of the caecum at its posterior part. Emphysema of the perineum and scrotum may arise from a wound of the bowel in the adminis- tration of an enema. In non-penetrating wounds of the thorax and abdomen, a small quantity of air may find its way into the areolar tissue in the immediate neigh- bourhood, in consequence of the movements of respiration. In compound fractures emphysema is often found extending some distance above and below the wound, if the patient has been carried some distance and the injured limb much shaken. Emjihysema from the gases produced by de- composition is only seenin cases of rapidly spread- ing moist gangrene. Pboqeess and Tebminations. — ^The effects of emphysema differ with the source of the gas. When the air comes from a superficial wound of the lung, it has no tendency to cause decomposi- tion of tlie effused blood with which it may come into contact. Thus, in surgical cases, no evil consequences result from emphysema around a simple fracture of a rib. This is explained by the fact that the gas in the air-vesicles is absolutely free from solid particles of any kind; as shown by Tyndall's experiment, in which the residual air, in forced expiration, makes a gap in the beam of an electric light when breathed across it. On the other hand, air admitted from with- out, as in a compound fracture, tends to favour the decomposition of the effused blood, and ren- ders treatment by occlusion or by antiseptic dressing difiicult and uncertain. In ordinary cases the effused air is rapidly absorbed without causing inconvenience of any kind. If the amount of air in the tissues be very great, and the case be complicated by pneumothorax, fatal dyspnoea may occur, unless relieved by treatment. Tkbatment. — The swelling itself requires usually no treatment, the gas being absorbed without difficulty. If it is complicated by pneumothorax, or if the dyspnoea be such as to threaten death, the wound, if one exists, must be opened up, or, if there is none, a free opening must_ be made into the pleural cavity. If the swelling be such as seriously to inconvenience the patient, a few punctures may be made with a triangular needle. Emphysema from intestinal flatus is always limited, and requires no treatment beyond that applicable to the cause of the escape "fgas. MabcusBeck. EMPIBICAL (Ir, by, and ntipa, experience). IMS term is applied to treatment founded on experience, as opposed to rational, founded on scientific reasoning. See Dishasb, Treatment of. EMPEOSTHOTOITOS {i^wpoad^v, for- wards, and Ttlva, I stretch.) — A bending or drawing forwards of the body, due to tonic con- traction of the muscles, observed in some eases of tetamc convulsions. See Tetanus. ENDEEMIC. 437 EMPYEMA (ir, in, and itiov, pus). — Strictly speaking this t^erm signifies a soUection of pus within the cavity of the pleura, but it is often conventionally used to denote any inflamma- tory effusion in that situation which has assumed a chronic character. See Pleura, Diseases of. EMS, in Germany. — Thermal muriated alkaline waters. See Minbbai. Watebs. EWCBPHAI.ITIS {lyKiiftaKos, the brain). Inflammation of the brain and its mem- branes ; or, more properly, inflammation of the brain-substance i^elf. See Bbaim; Inflamma- tion of. EKTOBPHALOCBIiB {iyK4(pa\os, the brain, and k^Xti, a tumour). — A hernial protrusion of a portion of the brain-substance through an open- ing in the skull, which may be either congenital or the result of accident. See Beain, Malforma- tions of. BWOBPHALOID (^7ice'ipa'">J. the brain), — A form of cancer, so named on account of its ob- vious resemblance to brain-tissue. See Canceb. BirCHOITDBOMA {iy, in, and x^'^fh cartilage). — A new-growth consisting of car- tilaginous tissue. See Ttmoubs. EWOTSTED {iv, in, and kviitis, a bladder). —Contained within a cyst. A term applied tc new-growths or collections of fluid thus enclosed. ENDAETBRITIS {iviov, within, and iprripia, an artery). — Inflamm.^tion of the inter- nal coat of an artery. The disease is generally chronic or" subacute, rarely aciite. T^otspeoial forms of endarteritis have been described, namely, endarteritis deformans, or atheromatous' disease {see Aetebies, Diseases of, and Athe- eoma); and syphilitie endarteritis, whicihmost frequently affects the vessels of the brain, but the specific nature of which has lately been questioned {see Syphilis, and Beain, Vessels of, Diseases of). ENDEMIC (^i", in, and iiiiua, a people).— This term is applied to diseases that prevail in par- ticular localities or districts, and which are due to special setiologioal conditions existing there. See Disease, Causes of. ENDEBMIC {iv, in, and Upita, the skin). A term generally applied to the method of in- troducing remedies through the skin. The homy layers of the cuticle interpose so effective a barrier between most remedial agents and the absorptive surface of the true skin, that the endermic plan of treatment when introduced was looked upon as a therapeutic gain. The ease with which drugs could thus be administered, and the excellent results obtained in neuralgia and other nervous affections, were held to fer more than counter- balance the pain of the application, the resulting disfigurement, and the occasional troublesome ulceration which ensued. And, although the hypodermic syringe, with its greater rapidity and efficiency, has rendered the endermic method almost obsolete, there are still circumstances which might induce us to use it. For instance, a blistered surface might be ready to hand; or' it might be considered advisable to combine counter- 488 ENUERMIC. iiritation with thesubsequentlocal use of morphia or other sedative drugs ; or it might not be pos- sible to procure an instrument for subcutaneous injection, or an invincible obj ection might be made to the needle-prick, which is sometimes a source of apprehension to sensitive natures, and we might then be glad to avail ourselves of a mode- rately efficient substitute. Mode of Application.— "We detach the epi- dermis either by any ordinary blistering ampli- cation, or by the button-cautery, and after its careful removal, we apply our selected drug to the raw surface, in the form either of powder or of an ointment, which latter plan has seemed to the writer rather more efficient, as ensuring more prolonged contact, the application being also less easily washed away by the efiiision of serum from the skin. The principal remedies used in this way have been morphia, which, in doses of from, a quaiter of a grain to two grains,- is un- doubtedly beneficial in oases of neuralgia, sciatica, and localized rheumatism ; strychnia, which was formerly much employed in amaurosis, lead palsy, infantile paralysis, and other nervous affections, in doses of from ^grain to one grain; and quinine, which in 6-grain doses has apparently cured oiistinate cases of ague. Egbert Faeutjhaeson. SNDOCABDITIS {hSoy, within, and Kap- Sio, the heart).-^Inflammation of the lining membrane of the heart. See Heaet, Inflam- mation of. EBTDOGASTEITIS (evSov, within, and yaariif, the stomach). — Inflammation of the mucous membrane of the stomach. See Stomach, Diseases of. ENDOMETBITIS (fyW, within, and ■fhrrip, the womb). — Inflammation of the lining membrane of the uterus. See Womb, Diseases of. EMTOPEKIOAEDITIB. — Inflammation of the endocardium and pericardium together. See Eeabt, Inflammation of ; and PEBiCAitDimi, Diseases of. EITEMA (iviijiu, I inject). — Stnon. : Lave- ment; Clyster; Fr. Clysth-e; Lavement; Ger. Klystier. iSEFiNiTioir. — An enema is a liquid injected by means of a suitable instrument into the rectum or the colon. Instruments. — Various instruments- are used for the administration of enemata : — 1. A simple elastic bottle -with ivory or gum-elastic pipe, which has superseded the old bag and pipe. 2. An india-rubber bottle with flexible tube at either end and double action. 3. An ordinary piston syringe, worked by the hand, which is either simple, or provided -with a double action, so as to supply a continuous stream. The «im- plex enema made by Messrs. Arnold is very con- venient ; the piston works on a spring, and re- quires no packing. 4. A Prench instrument, known as the irrigateur, worked by a spring. 5. The hydraulic enema, which consists of a piece of india-rubber tubing about six feet long, furnished with an ordinary ivory rectum-pipe at the one end, and a metal cone, or a screw nozzle, ENEMA, at the other. The tube, being filled with the injection, has one end placed iL the containine reservoir, or is connected by the screw ; while the pipe at the other end is introduced into the bowel. The vessel supplying the injection being placed on an elevation, the liquid gravitates into the bowel, filling the large intestine. When it is desirable to inject a large quantity the patient should lie first on the left side, then on the back and lastly on the right side, to promote the filling of the whole intestine. In all cases care should be taken to prevent the injection of air into the bowel, and also to ascertain that the nozzle of the injecting pipe is free in the rectum, not thrust against the sacrum, or into a hard fecal mass. Vaeieties and Uses. — The chief varieties and uses of enemata are as follows : — 1. Anthelmintic Enemata. — To cure thread- worms injections of salt and water, or lime'-ffater, or from two to four drachms of spirits of turpen- tine difiused by yolk of egg in four ounces of water are serviceable. The enema of aloes or of assafcetida may also be employed in the small quantity just named. 2. Aitispasmodlo Enemata. — Puerperal convulsions have been relieved by the in- jection of half a drachm or more of chloral hydrate. Injections of assafcetida or of rne are also given. Injections ' of warm water with 3ij or 3iij of sulphuric ether have some- times relieved spasmodic invagination of tie bowels. When the intestine is tympanitic and distended, the enema terebinthinse acts well as a stimulant and carminative. 3. Astringent Enemata. — These are used either to check diarrhoea, to arrest haemorrhage,, or to cure ulceration and mucous discharges. For the first of these purposes the enema opii is valuable. In cases of haemorrhage from the bowels, as well as from the womb, injections of ice-cold water are frequently used. Ulceration with mucous dischaige is often suooeBsfully treated by enemata of nitrate of silver (five grains to one pint of distilled water), of sulphate of zinc or alum (one or two grains to the ounce of water), or of sulphate of copper (one grain to the ounce of water). 4. Emollient Enemata. — Demulcents, such as decoctions of starch, linseed, or barley, or pure linseed oil, are at times used -with the object of imparting nourishment to the system, and of soothing an irritable mucous membrane. In dysentery, from four to six pints of warm water, or of milk and water, have been injected as an internal fomentation. 6. nutrient Enemata. — In cases of ex- haustion enemata of beef-tea and eggs beaten up are used ; abolit four or six ounces should be given at once. Should the rectum become irri- table, the irritability may be often lessened by adding a. few drops of laudanum to each enema. Defibrinated blood, in its recent or dried form, hsis lately been recommended as a material for nutrient enemata (see paper by Dr. Sansom on Supplementary Alimentation, Laneet,l&&l, vol.). p._288). The digestipn and assimilation of nu- trient enemata may be facilitated by the addition of preparations of pancreas and pepsine. Bee Peptonised Food, page 1116, ENEMA. ■ Injeetions of brandy and water, or teef tea Bnd brandy, liave been given with benefit in prostration from uterine hsemotrhage. 6. Sedative Enemata, — These are often em- ployed- in painful affections of the rectum and bladder. The enema opii, containing half a drachm to a drachm of tincture of opium, is well suited. In spasm of the bowels and in hernia the enema tabaci may be resorted to, but it may produce faintness and collapse. An infusion of twelve grains of dried belladonna leaf in six ounces of hot water is also used with advantage. 7. PurgativB Enemata. — These are used to overcome constipation. , For this pui^pose^in the case of an adult — from one to two pints of fluid must be slowly pumped into the bowel. If the process be conducted gradually, stopping oc- casionally and making pressure on the anus if the injection threaten to come away, as much as four_ or five pints can be got into the bowel. The injection should be retained as long as possible, as thus a complete evacuation is in- sured. As a general rule about a pint of liquid is enough, for an adult ; for an infant an ounce ; for a child of four years, four to six ounces. _ Compositim. — Soap and water, gruel with olive oil, castor oil, and sometimes oil alone, may be used. The enema magnesiiB sulphatis contains one ounce of epsom salts, and is an efficient' purgative.^ Enema aloes is also recognised. In cases of intestinal obstruction the Introduction of a large volume of soap and water— with oil, perhaps, added— by means of the gravitation- tube, may be had recourse to with advantage. Obstniction due to impacted faces genially yields to this method of treatment. The frequent use of very large injections is undesirable, lest undue distension result. The frequent use of injections washes away the mucus designed to lubricate the bowel. Sons 0. THOHOwaooD. BH-GADI3srE,UPPEB,in Switzerland.— A bracing mountain climate. Elevation of valley 5,000 to 6,000 feet. Season, June to beptember. See Climatb, Treatment of Disease EBTGHIEIir, in IVauce.-Sulphur waters. See MniEBAi, "Waters. , EBT&LISH OHOLEBA.-A synonym for simple cholera or choleraic dian-hcea. /See Oholebaic Diabehcea. EBTG-OBGEMElirT.— Overloading of the vessels, or of the heart, with blood. A synonym for congestion. See CttcviATioN, Disorders of. BETTEKALGUA (.';,Tepo^, the intestine, asdHKyos, pain).— SwoN. : Enterodynia; Neur- ralota mesmteriaa vel meneraica ; Colic. The terms enteralgia and colic—generally re- garded as synouymous-indade all forms and degrees of paroxysmal intestinal pain in cases where there is no febrile disturbance. Enter- S "?P}y'"g "^o™ especiaUy the neuralgic nature of the senson-motor disturbance, is some- mTJ l™3 f ', ^^ ^y°^^ ^^<> 1^0 Id that colic ZTJC: ■ 1^'^} i^ad-eolic is a typical example aadistingmshedfromsymptomaticcoliekypains- ENTOZOA. 439 is a visceral neuralgia. Itis likewise frequently applied to colic occurring in neurotic, asthenic, ansemio, or gouty subjects, even when there is a local exciting cause, such as flatus, retained fseoes, &c. ; and to conditions in which pain predominates over spasm. The clinical features of enteralgia are, however, indistinguishable from those of colic ; a similar local disturbance, ac- cording to its intensity, is reflected by the nerves to the heart and the peripheral arteries — tho action of the former becoming slow and feeble, and the latter contracting, hence arising the small, infrequent, tense pulse, the cool pale stin, and- the other signs of collapse which mark the distant effects of colic ; and, as in this disorder, the termination of the attack may be sudden, perhaps following the expulsion of flatus or fteces — a free perspiration, a copious flow of pals urine, the menstrual or loohial or other discharge, or a fit of the gout. Tebatmbnt. — The main indications in the treatment of enteralgia are to endeavour to re- move any cause of the pain ; and to administer opium or other anodynes for the relief of the suffering. See Cotio, Intestinal. Geoebe Oiivee. BBTTEEIO EBTEB. — A synonym for typhoid fever. See Typhoid Fevbb. ENTERITIS (fvreppi/, a bowel).— Inflam- mation of the intestines. See Intestines, Dis- eases of. EWTEEOOELB (eyrepay, a bowel, and K^\)j, a tumour). — ^A hernia containing a por- tion of bowel. See Keenia. ENTOPHTTB (linhs, within, and (f uTbi', a plant). — A plant parasitic in any part of the body. Entophytic Diseases are diseases that are sup- posed to depend upon the growth of such plants, as, for example, fungus-foot. Bee Fungus Foot or India. EHTOZOA {hThs, within,' and (mov, an animal). — This term not only embraces all the animal parasites coming tinder the category of 'worms,' or 'intestinal worms,' but also a great variety of creatures which take up their resi- dence in the soft and hard tissues as well as in the cavity of the digestive organs of their human and animal bearers. Under the article Paba- siTES is given a deiinition which will probably be found more comprehensive than any hitherto offered. In this place, with the double view of facilitating reference and supplying an epitome of the whole subject, a complete alphabetical list of the separate headings under which the en- tozoa are discussed in the body of this work is appended. The articles stand as follows:— Acephalocysts ; Ascarides; Bilharzia; Bladder- worms; Bothriocephalus ; Chigoe (Sandworm) ; Cysticercus; Demodex: Distoma; Dracunou- lus; Echinooooous ; Echinorhyuchus; Fasciola- Filai-ia; Filaria Sanguinis-Hominis ; Fluke- Guinea- worm; Haematozoa (Blood-worms) • Hel- minths; Hydatids; Intestinal worms; Lnm- bricus ; Measle ; (Estrus (Bots, Maggots, Insect Parasites, Gadfly); Oxyuris; Parasites; Peu- tastoma; Eound-WQrms; Sclerostoma (Anchylos- tomnm, Dochmins); Seat-worm; Tienia; Tape- 440 ENTOZOA. worm; Thread--«rorm ; Trichina; Trichinosis; Trichocephalus; Vermes; Whip-worm. The Ectozoa are noticed under the article Epizoa. T. S. Cobbold. EITTOZOON FOIiLICTTIiOETTM. — A Bjnonym of the animalcule of the follicles of the skin, otherwise named acarus (Simon), demo- des (Owen), and steatozoon folliculorum (Eras- mus Wilson). See Acaexjs and Demodbx. BNTBOPIOlir (^i*, in, and rfiira, I turn). — A morbid condition in which the eyelid is in- verted, so that its free margin is directed towards the eye. See Eyb and its Appendages, Diseases of. EITITKESIS (Jv, in, and ovfiu, I pass the urine). — ^Involuntary discharge or incontinence of urine. See Mictukition, Disorders of. EPHBLIS (^t1, dueto,and7iXios,thesun). — Stnon. : Sunburn ; Fr. EpheUde; Qer. SoniKn- fiechen. — This word is applied to pigmentary dis- coloration of the skin, of a brown, grey ,_ or black colour, resulting from the stimulus of light and heat, as of the sun's rays, or scorching by fire. Two principal varieties of the affection have been noted, namely; Ephelis solaria, and Ephelis ig- nealis. See Piqmentaet Skin-Disbases. Eeaskds Wilson. EPHEMEBAL EEVBR (!<()', upon, and illiepa, a day). — A mild form of milk-fever, so called on account of the rapidity with which it subsides, lasting not more than a day. See Milk- Feveb. EPHIDBOSIS (iirX, upon, and l'Sp6a, I sweat). — A term signifying a state of sweating, and synonymous with Idrosis. SeePEESPiBAnON, Disorders of. EPIDEMIC {epidemicus, affecting the people ; from ^irl, upon, and S^/toj, a people). — The word epidemic is used in two senses by medical writers and by medical men, namely, (1) in a general sense, and (2) in a technical sense. As a general term the word signifies 'com- mon to, or affecting, a whole people, or a great number in a community; prevalent; general.' {Webster's Dictionary.) It is in this sense that the word is used when it is applied to mental, moral, and social phenomena, as, for example, when we speak or write of 'epidemic suicide,' ' epidemic folly.' This employment of the word is consistent with received literary practice. Thus we read, ' There was a time when wit was epidemic.' (AthencBam.) Again, M. LittrA, writing to the Temps : — ' It argues^ great confidence in oneself and one's own enlightenment to treat with haughty disdain, and without reserving any compromise, the opinion of so many citizens, and to regard it as a case of epidemic aberration.' Asa technical term having reference to disease, the word epidemic has several different mean- ings attached to it. All these meanings include the notion of general prevalence among a com- munity or a people, but some of them would go on, beyond what etymology justifies, to attach a peculiar hypothetical or theoretical conception to the term. Thus (a) Mayne restricts the term to diseases which are contagious, making con- tagion the essence of epidemicity, as he would phrase it ; (4) Dunglison implies by the term a EPIDEMIC. particular constitution of the air ('consiitvlio aeris, or condition of the atmosphere ') ; (c) other authoritative writers use the term as signifying a widespread cause, telluric, atmospheric, cosmic, as the case may be, acting at the same moment of time on many individuals, or as something occult, regarding which speculation is vain, and which they designate epidemic constitution or The foregoing technical significations attached to the word epidemic are not less misleading than insufficient. Mayne's definition imposes an arbitrary limitation upon the meaning of the word, while it involves but a partial notion of the phenomena of epidemic prevalence of contagious diseases, Dunglison's definition does not rest upon a scientific foundation, and its phraseology, derived from a period when medicine was still hampered with semi-mystical speculations, can- not well be dispossessed of the vague traditional meanings which adhere to the word ' consdfcu- tion.' Other technical definitions (if that can be called a definition which makes obscure what should be rendered clear) rest on mere assump- tions or relegate the term to the incompre- hensible and insoluble. Of these last-named definitions L^on Colin has recently said :— ' They signify implicitly a common cause, ap- parently indecomposable, to which individuals are not exposed successively bnt simultaneously .... a something isolated, impersonal, inac- cessible to reason, detached from the disease itself, the epidemic genius [constitution, in- fluence] .... a creative force of the difierent epidemic affections, compelling, directing, ex- tinguishing them.' 'The promiscuous use of the word epidemic in medical literature and medical talk, and the different irreconcileable significations attached to it as a technical term, have been, and still con- tinue to be, sources of almost hopeless confusion in treating of diseases in respect to which the phenomenon of (etymologicaUy) epidemic pre- valence is observed. It is not difficult to appre- hend how this has come about. The diseases in question (the maris popmlarea of some writers) include among their number plague, the erup- tive and continued fevers, influenza, malignant cholera, &c. ' They have the peculiar character of attacking at intervals great numbers of people within a short period of time ; they distinguisli one country from another, one year from another; they have proved epochs in chronology; and, as Niebuhr has shown, have influenced not only the fate of cities, such as Athens and Horence, but of empires; they decimate armies, disable fleets ; they take the lives of criminals that justice has not condemned ; they redouble the dangers of crowded hospitals; they infest the habitations of the poor, and strike the artizan in his strength down from comfort into helpless poverty ; they carry away the infant from the mother's breast, and the old man at the end of life ; but their direst eruptions are excessively fatal to men in the prime and vigour of age. (Wm. Faee.) Exercising at all times in their greater and more fatal prevalence the pro foundest influence over the mind, as well of the people generally as of the medical pro- fession, these diseases, partly from the terror EPIDEMIC. 441 they inspira, partly from the extreme com- plexity of the phenomena they display, have formed a never-ceasing subject of the -wildest Bpeculation. No part of medicine has retained 60 much of the semi-mystieal teachings of the older physicians as that which relates to epi- demics, and general histoiy has contributed with medical history to propagate in regard to epidemics that habit of thought which refers the unknown to the ocCult— using the latter term in the sense in which it is applied with regard to the imaginary sciences of the Middle Ages. Much of the speculation as to epidemics which passes current for science at the present day is in reality an unsuspected continuation of the mystical teachings of earlier medicine : magnetism, or electricity, for example, taking the place of Saturn or Mercury in the scheme of causation. The terminology is modernised, but the underlying conception remains the same. Again, the' so-called ' precursors ' of epi- demics which still find a place ia treatises on medicine are the relics of the doctrine of por- tents of the Middle Ages. They rest on the assnmption of an epidemic being determined by gome common extra-mundane or intra-mundane cause, of which it is but one of several effects. The celestial 'portents,' such as comets and meteors, and the more manifest telluric 'por- tents,' sueh as earthquakes and volcanic erup- tions, have been discarded ; but the ' portents ' derived from exceptional developments of insect life, &om murrain, from unusual prevalence of certain diseases, and from remarkable perturba< tions of the weather, are retained under the denomination of * precursors;' For example, the earlier epidemics of malignant cholera which visited Europe were believed to have been heralded by an unusual prevalence of 'fevers' and of ^diarrhoeal affections. The epidemic of 1865-66 gave an excellent opportunity of study- ing the facts bearing on this question. Europe was taken by surprise when cholera appeared in 186S, on the south coafit of the Mediterranean, at Alexandria, and began thence to extend ra- pidly to the southern and eastern shores of that sea. It was not, indeed, until the disease had effected a lodgment in several parts of the Con- tinent that the attention of governments and the public with regard to it was fully aroused. No cliange of the public health in the several places visited by the epidemic had occurred of such a nature as to give rise> to any, even the least sus- picion, of impending pestilence. Moreover, not- withstanding the prevalence of steppe murrain and of cerebro-spinal fever in Northern Europe at the beginning of 1865, there was nothing to suggest (indeed it was not suggested) that these phenomena were ' precursors ' of, the coming epidemic of cholera, or of the extension of yellow fever to the shores of England the same year. In fact, the different occurrences were parts of contemporaneous rather than successive phenomena. The condition of the public health preceding the appearance of cholera in England, and especially in respect to diarrhoeal antece- dents, was made the subject of careful study by the late Professor Parkes and others. These observers failed to obtain any inkling of a change in the public health which could be re- garded as presaging pestilence — of the existence, in short, of any so-called 'epidemic constitution.' It is true that John Sutherland had described an jncrease of ' fevers ' and diarrhieal disease in Malta, as preceding the appearance of cholera there, in June 1866, observing that : — ' These facts are sufficient to show that long before cholera began to come towards the north-west, there were indications of a changed condition of the public health in Malta ; ' and after giving an account of two groups of choleraic cases which occurred in May, he adds, ' It appears to me scarcely possible to escape from the conclusion that long before cholera appeared in Malta, pos- sibly before the first outbreak in Arabia, the earliest wave of the coming epidemic had passed over those islands.' But while, according to Dr. Sutherland, the coming epidemic was thus clearly foreshadowed in Malta, no change in the puhlic health presaged its appearance in Gibraltar in July. The absence of all foreshadowing of the epidemic at Cribraltar can hardly be reconciled with the suggested presence of such foreshadow- ing at Malta. The facts which have been in- terpreted as presaging the appearance of cholera in the latter island are, indeed, to be regarded as coincidental rather than related. It is true, also, that MM. Didiot and Gruds have en- deavoured to show that prior to the appearance of cholera at Alexandria in 1865, choleraic dis- ease existed in Marseilles, and that the outbreak of the epidemic in the latter town was preceded by 'upe- constitution midicale ohoUrique.' The evidence they advance in support of their con- clusions simply shows that deaths from infantile cholera, which, as they, properly remark, is ' a la v&ritA, friquente a Marseille,' and from so- called ' sporadic ' cholera, are apt to occur in Marseilles during the months of May and June, as perhaps in every city and town of southern and central Europe, Another illustration to the same effect as the above, in reg.ard to the 'precursors' of epi- demics, is furnished by; the "history' of the small-pox epidemic of 1869-73, the greatest epidemic of this disease in recent times— a true pandemic (rdvirinos, from irav, all, and S^juos, the people) extension of the malady. The aoutest observers were taken by surprise with the ma- lignity and difiusibility of the disease during the epidemic — phenomena wholly unforeseen. Here, again, the study of the diseases preceding or accompanying the epidemic yields no facts. of variation in their prevalence, from which the approach of a great epidemic might have been inferred, nor give any hint that they were depen- dent with it on some common cause. There were concurrent phenomena of disease during both epidemics, but they were concur- rences of certain diseases existing at the same time among the population affected by the great epidemic, and some of them probably having certain secondary elements of causation in com- mon. This is a different question to that of an assumed ' epidemic: influence ' or ' epidemic con- stitution." _ The subject of the conmrrenoe of epidemics is a new field of investigation, which has lately been opened by an arithmetical study of Qeorge Buchanan's, relating to epidemics in numerous extra-metropolitan registration sub- 442 EPIDEMIC, districts in England. This study was directed to ascertain — as necessarily introductory to a statistical investigation regarding community of causation or mutual antagonism of various epi- demics — the arithmetical prolability of, their concurring as a mere matter of chance. The data used were taken from a particular quarterly return of the Eegistrar-General, and they ex- tended to 946 occurrences of epidemics (small- pox, measles, scarlet-fever, diphtheria, ■whoop- ing-cough, fevers, and diarrhoea and simple cholera) in 1,490 districts. The result showed a good deal of general correspondence between the calculated number of concurrences and the actually observed number, but with departures, of more or less magnitude, of the actual from the calculated degree of concurrence, which de- serve to be followed up by further investigation. The departures were shown in an excessive fre- quency of the concurrence of measles with the other epidemics, of diarrhoea with all other epi- demics except small-pox, and of scarlet-fever with the ' fever' of the Eegistrar-General. On the other hand, it is of interest to observe that there was an absence of any notable excess of frequency of concurrence between scarlet-fover and diphtheria, or between scarlet-fever and ' whooping-cough. In view of the extreme looseness with which the word epidemic is used in medicine, some- times simply as a descriptive term, sometimes as a technical or quasi-technical term involving various hypothetical and theoretical conceptions inconsistent with each other, and sometimes as implying an occult influence, it would be well if it could be discarded from medical literature and language. Epidemic, in its present medical uses, is an instance of words which, as Bacon Bays, when writing of the effects exercised by a bad and inapt formation of words on the human mind, ' force the understanding, throw everything into confusion, and lead mankind into vain and innumerable controversies ' {Nov. Org. App. 43). But the retention of the word, from its long and familiar usage, is practically a necessity in medicine ; moreover, it would bo difficult if not impossible to find a substitute which, if the word be used in its ordinary signification, would supply its place. It is suggested here that the technical mean- ing of the word epidemic should be assimilated to the common meaning ; or, more accurately, that the technical meanings now attached to the word should be abandoned, and the word used in medicine in the same sense as in general literature and in ordinary converse; that is to say, as a merely . quantitative term appli- cable to particular phenomena, whether patho- logical, mental, or social, in so far as they are ' common to a whole people, or to a great number in a community ; ' or in a word are ' prevalent ' or 'general.' In this way not only would the con- fusion arising from the present medical uses of the word be got rid of, but the scientific study of epidemic phenomena would be facilitated, in the only direction which gives promise of suc- cessful issue. As L^on Colin has aptly written : ■ — ' It is the disease which constitutes the epi- demic, not the epidemic the disease. The evil always remains the same, the number of affected EPIDEMIC MENINGITIS. alone being increased.' The medical study ,vf epidemics is essentially a study of the indivi. dual diseases which are apt to become epidemic, and not, as has been too commonly the case hitherto, of some figment of the imagination {epidemic constitution, or influence, or ffeniua), apart from the diseases. It is only in propor- tion as researches have been directed to particu- lar diseases liable to become epidemic, and to the conditions under which they prevailed epide- mically, that recent advances in our knowledge of epidemics have been made. In this country the two most important events which have oc- curred in this connection of late years were the discrimination of imhusiiiom typhoid, by A. P. Stewart and Wm. Jenner, and the researches on the typhus of homed cattle (steppoiimurrain, cai- tie-plague), promoted by the Eoyal 'Commission of 1865-66, on Cattle-Plague. The discrimina- tion of typhus from typhoid proved that the volu- minous speculations which to that time were cur- rent on the epidemiology of the continued fevers of this country, then regarded as but one disease presenting several varieties, were for the most part meaningless verbiage, by showing that the two most common forma of fever were distinct diseases clinically, pathologically, and setiolo- gically. This discovery proved to be the in- auguration of a true method of investigation concerning epidemics, by making evident that epidemic phenomena did not admit of accurate study, except in so far as it was based upon a just discTimii;iation of the diseases manifesting them, and upon their clinical and pathological histories. The same lesson was taught, not less clearly, although- in another fashion, by the re- searches promoted by the Eoyal Commission on Cattle Plague, with which the names of Lionel Beale and Burden Sanderson are especially con- nected. These researches demonstrated the essentially infectious nature of the malady, and that its prevalence was dependent upon the dis- semination of the infection, directly or indi- rectly, from animals sick of the disease to the healthy. It was shown, indeed, in the patho- logical laboratory, that preconceived doctrines of some occult epidemic influence which had been submitted to the Commission as determining the prevalence of the cattle-plague had no existence in fact when the disease was subjected to ex- perimental study, and that its conditions of pre- valence were fully within human control. These researches proved the starting-point of those im- portant investigations on the intimate pathology of contagion carried out byBurdon Sanderson and Klein, for the Privy Council, under the direction of John Simon, and to which Wm. Boberts and others have independently contributed so largely — investigations which promise speedily to revo- lutionise our knowledge of the intimate pathology of infectious diseases. It is interesting to note that the Eoyal Commission on Cattle-Plague in- cluded the following medical members : — Eichard Quain (M.1).), H. Benee Jones, E. A. Parkes, T. Wormald, and E. Ceely. See also PEEioniciii IN Disease. J. Netten Eadcuffe. EPIDEMIC CEBBBB.O-SPINAL MB- BTIITGITIS. — A synonym for cerebro-spinal fever. See Cerebeo-spimai. Feveb. EPIDEMICS, OCOUEBENCE OF. EPIDEMICS, Ooourrenoe of. See Peeio- DiciTT IN Disease. BPIDBBMIS, Diseases of. See Skin, Diseases of. EPIDERMOPHYTON {M, upon; i4piia, the skin ; and ^ut!ii', a plant). — The name of the epiphTte, or parasitic fungus, of phytosis versi- color, also called Microsporon. See Epiphtta. EPIDIDTMITIS (M, upon, and 51!u;jos, a testicle). — Inflammation of the epididymis. See Testes, Diseases of. EPIGASTEIO BEQION.— This region is situated at the upper and central part of the abdomen, just below the ensiform cartilage, and between the sloping margins of the thorax down to the level of the ninth cartilage, corresponding to what is popularly known as the, 'pit of the stomach,' The structures within the abdominal cavity which normally occupy the epigastrium are the greater part of the stomach, a small portion of the liver, and more deeply a part of the pancreas, the aorta giving off the coeliac asis and superior mesenteric branch, the vena cava inferior, the veins forming the commencement of the portal vein, the receptaculum chyli, and the solar plexus. Clinioal Investigation. — Clinically, it will be found that patients frequently complain of abnormal sensations specially, referred to the epigastrium. These are generally associated with the stomach, and may merely amount to a sense of discomfort, fulness, or tightness ; or to actual fain of varying character, more oi less severe according to the condition upon which it de- pends, and often much influenced by the inges- tion of food. Sensations of trembling, throbbing, or sinking in the pit of the stomach are also of common occurrence, especially in females. These are often merely of a nervous character. In some cases there is evident tenderness, either over the entire epigastrium or in some limited spot, and it is important to recognise whether this Is superficial or felt more or less deeply, for it may be connected with the superficial struc- tures, the peritoneum, the liver, the stomach, or the pancreas. The sensation experienced in connection with hunger is referred mainly to the epigastrium, and it may be of a painftil cha- racter. Here may also be noticed the epigastric pain termed gastralgia or gastrodynia, which is usually felt chiefly when the stomach is, empty, being relieved by taking food. A most unpleasant sensation at the pit of the stomach accompanies nausea, which may be of a horrible but indescribable character; while violent vomit- ing or retching causes considerable pain or aching in this region, partly associated with the stomach, partly with the abdominal walls. Heartburn is another sensation which seems to start from the epigastrium. Sometimes the pain is situated deeply, or shoots towards the back. This may depend upon disease affecting the posterior wall of the stomach, pancreatic disease, aneurism, or other causes. A sensation of tension or actual paia is sometimes experienced just below the ensiform cartilage in cases where the diaphragm is much pressed downwards, as from extreme EPiaASTEIO BEGION. 443 emphysema, abundant accumulatioti of 6aid or air in the pleura, or extensive penuai